Answers to commonly asked questions about dogs' ACL/CCL ligament injury and treatment
and tips on handling problems that arise during recovery.
Is there a schedule I can use for activity increases as Fido improves?
There is variation in the severity of these injuries,
and there are differences between the dogs themselves. Each dog's recovery must proceed at its own pace. It
is not good to set up a timetable in advance such as "10 minutes walks 4 times a day beginning
with week 9" and then try to fit Fido into that pre-determined schedule.
---- It is best to have an
unregimented approach which has as its primary rule that you will always avoid too much activity. It is important to
be cautious. The most common error people make is to push forward with activity increases too quickly.
the recovery with a minimum of activity. Watch for a little improvement. Increase activity slowly & cautiously
once you see improvement. Reduce activity to a minimum at any sign of a problem. A decrease in use of the leg or an increase in limping or stiffness after resting or other symptoms tells you: "Too
much activity. Too-much-too-soon for that recovering stifle." Decrease activity to a minimum if symptoms increase.
Then, when the symptoms lessen, introduce increased activity more slowly.
is important that increases in activity be eased into slowly. Increasing slowly and watching carefully
for indications of trouble will usually give you the ability to prevent a serious re-injury. Always be careful to prevent
those high-stress events like taking off in a run after a squirrel which can cause major setbacks in recovery!
---- Recovery will
take months. Your role is to maintain the careful restriction and supervise the slow incremental increases in activity
and provide the high-quality food and supplements your dog's body needs.
---- As you look for improvement in your dog, it can
be frustrating to compare today with yesterday. Improvement usually comes so slowly that the difference between
one day and the next is not apparent. Keep track of your dog's condition with written notes or video so that you
can compare today's condition to two weeks ago / a month ago. This will let you see if slow progress is taking place.
Pain Medication? Inflammation
Drugs which are anti-inflammatory, usually
NSAID drugs (Non-Steroidal Anti-Inflammatory Drugs) like Rimadyl, Deramaxx, Metacam, etc, are
commonly prescribed for dogs with ligament injuries. While these drugs may relieve the pain and reduce the swelling
that accompanies a sudden traumatic injury, there are good reasons to minimize their use.
---- It is important for you to understand that there is a difference between Acute Inflammation and Chronic Inflammation. People may think of inflammation as always being a bad thing, but that is not true. Inflammation is a necessary component in the healing process. The body responds to injury with
a sequence of events that begins with an influx of inflammatory cells and blood. The inflammatory cells remove debris and
recruit cytokines and other growth factors toward the injury site. This inflammatory phase is partly mediated by the same
prostaglandins that are blocked by NSAIDs. In a healthy healing process, a proliferative phase consisting of a mixture of
inflammatory cells and fibroblasts naturally follows the inflammatory phase. The fibroblasts build a new extracellular matrix
and persist into the final phase of repair, the maturation phase, where functional tissue is developed. Each phase of healing
is necessary for the subsequent phase. By blocking the inflammatory phase, anti-inflammatory drugs including NSAIDs can inhibit
healing and cause a less desirable end result. There are numbers of studies showing that these drugs negatively
influence healing / recovery in various kinds of injuries.
NSAIDs all have risk of stomach ulceration as well as liver and kidney damage.
---- These drugs have a place in treatment because they are effective at reducing the pain of injury and reducing excessive swelling.
But vets often fail to inform people of the drugs' undesirable aspects. I recommend that use of
anti-inflammatories be minimized. Give these drugs to your dog in the lowest effective dose for the shortest time possible.
Your vet may be handing out NSAIDs without warning of their risks, leaving you with the impression that these drugs are safe
& good for use 'just in case' Fido might be feeling some discomfort. This is not true.
"But Max, My own doctor as well as Fido's
vet prescribe NSAIDs all the time for all kinds of sports injuries and other trauma."
In the past, the extent of the negative aspects of these drugs was not well known, and
they were prescribed without the caution we now know is appropriate. If often takes a long time for medical practice
to catch up to current knowledge. While there is some conflicting evidence, it is well established that these drugs
have serious risks. Use them with care.
---- Also, It is important to remember that
the pain Fido feels when he puts pressure on that leg is nature's way of saying "Don't do that!"
If you've ever had a sprain or other joint injury to an ankle or knee, you know that after the injury the pain soon eases to
being mild except when you try to stand on the foot of the injured leg. Then the pain tells you in no uncertain terms
"Don't do that! Don't try to bear weight on that leg!" If I had a sprain or other joint injury
and took a pain reliever which completely stopped the pain, I could walk using the injured leg much more than I should and
might do serious further injury to the joint by using it too-much-too-soon. We need to keep weight off an injured joint
to give the body time to work on healing, and the pain we feel when we try to use the injured joint to bear weight sees
to it that we do that.
---- So you see we do not want to try to medicate away Fido's limp. Pain medication is helpful
right after traumatic injury (when pain may be bad even when Fido is at rest) because the drug allows a
dog to rest comfortably. But extended ongoing use of pain medication can easily become counterproductive.
We want to alleviate pain Fido feels when at rest, but the pain Fido feels when he stands on the leg and puts pressure
on the joint encourages him to be gentle with the injured joint, which is good.
---- People often do not know that NSAIDs have an adverse effect on healing, as well as risks of severe damage to a dog's liver, kidneys,and digestive system, so they may cheerfully go on giving their dogs these drugs long after it would have been better
to stop. Many vets do not inform clients about the negative aspects of NSAIDs, and may prescribe NSAIDs for
dogs who are not feeling significant pain. Please do not give your dog any NSAID drug just because you think Fido might be uncomfortable and you want to do something to help. These drugs have serious risks and should not be used casually as though they are perfectly safe.
---- I would prefer to stop pain medication as soon as that can be done
without Fido being too uncomfortable when at rest. If a dog is able to sleep comfortably after pain medication
is removed, that indicates his pain is not too bad and he will be fine without pain medication. Being unable
to sleep would indicate that pain medication should be resumed. Then try removing medication again in a week or so.
If you need to continue pain medication after the first several weeks, and the original medication is a NSAID, ask your vet
to prescribe a non-NSAID pain medication like Tramadol (Ultram, Tramal, others). Be sure he understands you want a non-NSAID,
non-anti-inflammatory drug for pain. (Many times people ask for a different drug because their dog is
having trouble with the specific NSAID originally prescribed, so the vet might not clearly understand your intention
is to stop giving anti-inflammatories and could automatically respond to requests for a different drug by prescribing
a different NSAID.)
Aspirin is a non-prescription NSAID drug. Regular aspirin is much more likely to cause stomach trouble for dogs than
is Buffered Aspirin. Like all NSAIDs, Buffered aspirin should always given with food. Never on an
---- Buffered aspirin is not enteric-coated aspirin. The use of enteric-coated aspirin is questionable for dogs. There are different opinions among vets about using enteric-coated aspirin. I would prefer that dogs not be given enteric-coated aspirin. If you want to give aspirin, give buffered aspirin. Just as with all other NSAIDs, never give aspirin on an empty stomach.
---- The suggested aspirin dosage for dogs is 5-15mg per pound twice
a day. (One 325mg buffered aspirin tablet per 30 pounds is slightly over 10mg per pound).
---- Be watchful when using any pain drug for indications of a problem.
Watch for signs that your dog's stomach is upset. If he stops eating or shows other indications of a problem caused by the NSAID, stop giving him the
NSAID immediately. Don't keep giving the drug.
---- Aspirin, Rimadyl, Deramaxx, Metacam, etc, are all NSAID drugs. Don't ever give two different NSAIDs
at the same time, nor switch to any NSAID from another NSAID until the body has had time to clear the previous drug.
How long this takes depends on the particular drugs. When switching to buffered aspirin, wait at least one day.
Be Watchful When Using prescription NSAIDs
Rimadyl, Deramaxx, Metacam, etc, can cause health problems including very bad kidney and/or liver problems in a small
percentage of dogs. These can be useful drugs, but they have this risk. Some dogs take these drugs for years and it
helps them with pain they have from some condition. But for a small percentage of dogs these drugs can be deadly. A
bad reaction can come immediately, or after a few days or a few weeks or longer. Usually dogs recover well if the drug
is stopped soon enough, but not all recover. While the rate of deaths for dogs given Rimadyl etc is small, these
drugs are nevertheless not something you want to use unless there is a good reason. If you are giving a dog any pain
medication and see any changes that could indicate internal difficulties, stop giving the drug immediately. Here's the
list of signs that a dog is reacting badly to a NSAID drug. If you see any of these, stop the drug immediately:
Adverse reactions may include decreased appetite, vomiting,
diarrhea, dark or tarry stools, increased water consumption, increased urination, pale gums due to anemia, yellowing of gums,
skin or white of the eye due to jaundice, lethargy, incoordination, seizure, or behavioral changes.
---- It's always a good idea to do a websearch on any drug and become
as knowledgeable as possible about the risks involved in its use. Don't just search the name of the drug and stop
after reading the first few informational pages. Add 'complications' 'risks' 'adverse effects'
to the drug name in your searches.
What is meant by 'Activity Restriction'
Restriction during non-surgical recovery or after surgery means
preventing all overly stressful activity and greatly reducing all activity. Only very short leashed walks to empty bladder
& bowel at first, increasing to short 'sniff & stroll' walks which gradually lengthen as recovery proceeds.
Permit only gentle activity which puts little pressure on the injured joint(s) for at least several months and perhaps longer
with severe injuries. All excessive stresses must be avoided. 'Excessive Stress' is caused by any activity
which puts more than minimal pressure on the legs, such as running or jumping. Even gentle walks can be excessive if
they go on too long. A short walk every few hours is preferable to a longer walk once a day.
--- But 'Restriction' does not mean 'Immobilization'.
Research shows that moderate gentle use of the joint leads to a better long-term result than immobilization of the joint.
Sometimes people assume that keeping the dog crated all the time or in some other way preventing almost all use of the leg
is the best way to prevent re-injury. But this doesn't lead to the best possible recovery for the joint. Moderate
use of the leg during which the dog can move the leg through its normal range of movement without excessive stresses is the
ideal. Swimming is great. Slow walking on a soft surface like grass for short distances is good. Being able
to move around inside the house at will is good. Always provided that running and jumping etc are prevented. Some
dogs are so high-energy that crating them is the only way to prevent jumping and other over-stresses. You know your
own dog best and how best to prevent excessive stresses while allowing very moderate, gentle use of the leg.
---- With some high-energy dogs, attempts at proper restriction may seem hopeless because the dogs are
so bouncy. Do your best and judge by whether they are improving. If a dog is improving over time--- limping less
/ putting weight on the injured leg / etc --- then the recovery is succeeding. The stifle(knee) is being made
stable by the build-up of new tough, fibrous supporting scar tissue.
How Can I Tell How Much Activity To Allow? As My Dog Improves, How Do I Know
How Long A Walk Is Too Long?
---- With a less-than-severe injury, or after a severe injury has improved somewhat, you don't need
to restrict gentle activity nearly as much as is appropriate in the early period just after a severe injury, but that doesn't
mean that restriction should end. You must still avoid all running & jumping & other activities which put too
much pressure on the joint. When improvement is seen it is good for a dog to be somewhat active in gentle ways such
as short leashed walks, but it is still possible to overdo gentle activity and caution is needed. Activity is good provided
it is not excessive.
------ Activity can be excessive in basically two ways:
-- Anything that puts a lot of pressure on the joint like running, jumping etc
-- Any low-stress activity which goes on too long.
Here's why: The joint is held together by muscle and other joint structure as well as the ligaments.
Different dogs have different muscular ability to hold the joint tight. (This is why vets may find with some
dogs that they cannot manipulate a joint to try to discover 'drawer' movement at the joint. The dog may tense
the musculature around the joint and the joint is held firm, regardless of the condition of the ligaments. When a vet
finds that the dog does this he will want to use an anesthetic to make the dog unconscious for the manipulation.) But
these muscles aren't able to do all the work of continual stabilization without the ligaments there to do their job, and
are only able to maintain stability for a short time before they are exhausted. Once they reach exhaustion on too long
a gentle walk, the joint will become loose. Therefore more subject to further injury to joint components or damage to the
developing scar tissue buttressing. This is why longer periods of gentle activity are not appropriate.
-- However, shorter periods of gentle activity are helpful for the recovery. Proper gentle joint
movement cyclically compresses then releases the meniscus, pumping nutrient-bearing synovial fluid around inside the joint
capsule. Moderate gentle activity minimizes overall muscle atrophy from inactivity and encourages proper scar tissue
development to support the injured stifle. So short periods of gentle activity like short sniff-n-stroll walks are very
good, but longer walks are not good. How long a walk needs to be to be 'too long' depends on the dog
and the condition of the joint. It is a judgement you need to make based on Fido's symptoms during activity, after
activity, and following rest after Fido's activity. Basically, during recovery it is best to make walks quite short
and do more of them, leaving time between for resting the recovering joint.
-- Here's an example for comparison: For a dog beginning to improve from stifle ligament injury,
a four minute walk 6 times a day would be the same amount of walk-time per day as a 24 minute walk once a day, but the 4 minute
walks would be very much preferable. I'm not recommending that specific schedule. It's just an example
to illustrate the point. Each dog's activity as he moves through his recovery must be determined individually for that dog.
Dogs with minor injuries or dogs further along in recovery from more severe injury will be able to have longer walks than
dogs with greater instability / vulnerability to excess.
---- You should always be
cautious and do less than your dog wants to do. Dogs will always want to do more that they should. Be cautious
about activity and if you see improvement over time, you will know that the joint is becoming more stable. Improvement
is usually slow. Improvement can be seen over the weeks & months by comparing the dog's condition to his condition
several weeks previous.
---- All running & jumping put too much stress on the joints and must be avoided during recovery.
A gentle walk is excessive which goes on so long that it causes or increases symptoms during a walk, after a walk, or after
rest after a walk. Walking on a soft surface is greatly preferable to pavement. Grass or other soft surfaces offer
less impact-stress to the leg than a hard paved surface, and the slight unevenness of a lawn or leafy path is better for the
recovering joint than a flat hard surface like pavement.
---- All that may sound more complex than it really is. The important thing is just this: Reduce
stresses on the joint to a minimum, and be patient.
Months have gone by since Fido's injury. He has not been restricted.
Is it too late now? Would surgery be better now because so much time has gone by since the injury?
is never too late. Begin restriction now. While it would be best to begin restriction immediately after the injury,
this seldom happens. Most people facing this problem for the first time do not recognize the nature of the problem at first.
They don't know that restriction is required. Sometimes the ligament slowly degrades and there is no sudden injury
event. When there is a sudden injury event they may mistake the ligament-related symptoms for some other kind of injury.
For these and other reasons it is very common for there to be a length of time pass before the problem is understood to be
ligament-related and restriction begun. But most dogs do respond well to restriction even when the problem has existed for
a long time. It is never too late to begin restriction.
---- Surgery does not become a more appropriate treatment
option because time has passed since the injury. Restrict the dog carefully starting now, regardless of how long the problem
|Tigger swimming in pursuit of geese
|Tigger thought it was unsporting to wait for a goose to be shot before retrieving it
as Therapy ---- If possible I would have a dog swim as therapy
during recovery. Many people have written me that swimming was very helpful in their dogs' recoveries. Swimming is great for dogs with ligament injuries because:
1) The non-weight-bearing
nature of swimming puts much less stress on the joint than walking, and the water offers only limited resistance to movement.
Swimming lets the dog get exercise which helps maintain muscle with little risk of injury to the recovering stifle.
2) While the dog is swimming the joint can travel through a normal range of movement. This encourages the newly forming
joint-supporting tissue to develop in such a way as to allow a greater range of movement after healing is complete.
And the gentle, low-stress movement also helps with healing other joint components by circulating the joint's synovial
3) Swimming gives the dog a safe outlet to burn-off that
Use Caution -- When you take your dog on a trip to go swimming, be aware of the risks of excessive stresses
when he is not in the water. Don't allow running into or out of the lake. Nor jumping into or out of the car. The stresses
involved in getting Fido into the water and then getting him home must not be excessive.
---- Swimming has been great therapy for many dogs during recovery without surgery, and swimming is also good post-surgically.
Many people who have used swimming as therapy during recovery are very enthusiastic about it. But if swimming is not a possibility
then a dog can still succeed in recovering without it. Swimming is great, but not a necessity.
---- Being able to move the joints without bearing full weight is the reason swimming is so desirable.
If your dog doesn't like to swim, a flotation vest may be a good idea. Flotation vests are helpful for poor swimmers and for older dogs who prefer less exertion. But be sure to get one meant for dogs to wear while swimming. There are flotation vests for dogs which are intended to simply keep a dog afloat if he falls off a boat. These are not good for swimming because they restrict leg movement. The 'Ruffwear K-9 Float Coat' is one example of a good flotation vest for a dog. There are several other brands which also allow full leg movement and provide well-distributed buoyancy. Another possibility for non-swimmers is wading in water that comes up high on Fido's body. For wading-as-therapy we want the water as deep
as Fido finds acceptable with his feet on the bottom. While he is wading in deep water the water supports a large part of the dog's weight, lessening the
burden on the joints. For dogs who are non-swimmers and for old or sick dogs for whom swimming would be too strenuous,
deep wading like that is a good alternative to swimming.
be helpful if there is no body of water available to you for simply swimming.
I would prefer free swimming
at the dog's own pace to any other therapy. But if this is not an option for you and Hydrotherapy using an underwater
treadmill is available, Hydrotherapy can be helpful. However, you need to be aware that there are therapists
who are too aggressive. An overly aggressive hydrotherapist might set the speed and time for Fido's underwater
treadmill session too fast and too long, or in some other way push the dog too hard. This is not unusual. If
your dog's symptoms are worse after hydrotherapy or worse the day after hydrotherapy, that should alert you that there
is a problem with the therapist being overly aggressive. A good therapist understands that a joint injury is very different
from a muscle injury. The joint needs gentle treatment as it gradually re-establishes stability after a joint injury.
If you interview a therapist and her description of what she intends as therapy focuses on 'building strength' or
're-building muscle', then she is the wrong therapist for joint injury recovery therapy. Re-building atrophied
muscle is part of recovery, but not the correct principal goal. When the joint is stable, the dog will know that
it is stable and will use the leg. This will re-build muscle. You couldn't stop it if you wanted to.
The primary goal of a joint injury recovery must be regaining stability and resistance to further destabilizing
injury. This requires gentle moderate use and time. In recovery from a muscle injury or other situation where
rebuilding strength is the goal but there is no joint instability problem, muscular strength and mass are increased by exhausting
the muscles. This muscle exhaustion sends the message to the body that increased muscle is required, and the body
responds by building muscle tissue. But if you exhaust the muscle tissue around a de-stabilized joint, you cause
the bones to grate and grind against each other at the joint. This can easily result in permanent damage. Gentle
use of the leg which provides a near-normal range of movement without any kind of excess stresses is the ideal therapy
for joint injury recovery. Swimming at the dog's own chosen pace is the perfect exercise therapy for joint injuries.
make the long days of recovery even longer for a dog.
---- Find things to do that don't require a lot
of use of the legs. Bones are very nice! Fido probably enjoys a ride in the car. Toys can fill the hours for some dogs. Some
like to watch out the window or watch TV. Make Fido's short walks 'Sniff-N-Stroll' walks. Slow meandering
walks at the dog's chosen pace which include stopping to sniff at this and that. A ride in the car to someplace
where a dog can have a liesurely 'Sniff-N-Stroll' on the grass among trees & shrubbery will be a high point in
the day and help Fido keep up in good spirits.
What About Overweight Dogs?
Many dogs who have ligament injuries are
overweight dogs. While it is important in the long run to get that excess weight off the dog, it is very difficult to lose
weight while activity is severely restricted as it must be for the early weeks of ligament injury recovery. To lose weight
in a safe and healthful way requires exercise. So it is best to make the first priority the joint's recovery, and the
secondary goal the weight loss. The dog needs proper nutrition to heal that injured joint. Once the recovery is underway and
you see improvement in the use of the leg, it is appropriate to slowly increase exercise. At that point it is possible
to begin to work on the weight problem. One thing you can do from the beginning that will help with weigh loss even while
the dog is sedentary is to switch to a no-grain diet. There is more about this on this website's 'Nutrition &
Supplements' page. Also, it is possible for a dog to get exercise by swimming while recovering from a ligament injury.
Swimming is great exercise and great therapy for joint injury too. Overweight dogs can recover from ligament injuries, but
it is important for long term joint health to lose that excess weight. All the dog's joints are stressed by that weight.
As a dog ages, problems will arise in the weight-bearing joints for overweight dogs.
What might go wrong during recovery?
The biggest risk for a dog is doing too-much-too-soon and re-injuring
the joint. The most common mistake people make when they see that their dog is improved and no longer limping is to
decide that the dog must be almost fully recovered. So they increase activity too much or even allow normal activity to resume
abruptly. A setback in recovery often results. The dog may not have been limping, but that stifle was far from fully recovered.
It will take months more before it is as secure from re-injury as it can be, and meanwhile it is the weak link in the leg.
The only way to know how much stress it would take to overwhelm the vulnerable recovering stifle would be to push it to the
point of failure. The wise course is to be cautious and slow in increasing activity. Many dogs have had re-injuries because
their people went too quickly in increasing activity. The risk of re-injury is minimized when you increase activity prudently.
When is recovery complete? After how many weeks of restriction?
When the limp is gone? When?
Once the original 8 week period of restriction has indicated by improvement in Fido's condition that non-surgical
recovery is underway, don't try to regulate or judge the dog's recovery by the calendar. Don't think "It
has been X weeks of restriction so this recovery is complete and Fido can now be free to run." Improvement during
the early weeks of restriction shows that the joint is re-stabilizing. This indicates that the dog can almost certainly re-stabilize
the joint without surgery. But it is not possible to say how long this will take. Continue to slowly and watchfully increase
activity until you have reached normal levels. Watch the dog, not the calendar. A few dogs recover well relatively quickly,
while most others take much longer.
---- Sometimes people want to set up a schedule of exercise weeks in advance. I believe this is a mistake. I think
the best strategy is to take it one day at a time, deciding as you watch your dog how much activity is right. Always being
cautious. Cautious and patient people do best. People who push for their dog to do more and do it sooner are much more likely
to have setbacks / re-injuries. Sometimes it takes a setback to teach someone the value of a slow, cautious, incremental approach
to increasing activity during a ligament injury recovery. I was like that, as have been many others. Learn from our mistakes.
Patience and caution and careful attention to proper restriction are the keys to success.
The vet says to "rest" Fido four weeks, then bring him back in to see the vet again.
If Fido hasn't recovered in the four weeks, the vet says he will need surgery.
---- Some vets will recommend surgery for a dog who has not recovered
after two weeks or four weeks. While minor injuries will have resolved in this short time, in cases where there is more than
slight ligament damage four weeks is far too little time to judge if the joint is capable of re-stabilizing without surgical
intervention. I know of many instances where no improvement was apparent in the first month, but then slight improvement was
clear at two months and the dog went on to a good stable recovered stifle without surgery. If your vet tells you two or four
weeks after beginning restriction that surgery is necessary, please remember that this is far too soon to make that judgment,
and that there is no good reason not to wait 8 weeks before considering surgery provided proper restriction is maintained.
---- Noticeable Improvement
is what you are looking for at 8 weeks, not full recovery. The fullest possible recovery will take longer, perhaps much longer,
but improvement shows clearly that Fido is slowly stabilizing that injured joint.
The vet said "Rest Fido 4 weeks, and if he is better then he can be free to run & play."
So we did that, but then Fido was limping again a few days after being let off restriction and the vet now says he needs surgery.
---- Fido re-injured that joint because even though his symptoms
had improved in four weeks that joint was still the weak link in his leg. Four weeks is much too soon to resume normal activity.
The new supporting tissue at his stifle(knee) was still fragile and easily torn up by the stresses of normal activities. Fido
needed very slow careful incremental increases in activity over at least several more months.
---- After a re-injury like this Fido may be starting over on his recovery, but
he is not any more likely to need surgery than after the original injury. If he is carefully restricted and improves
over the next eight weeks, he almost certainly does not need surgery.
The vet says my dog has a 'full
tear'(or 'complete rupture'). He says a 'partial tear' might recover without surgery, but 'fully torn'
ligaments must have surgery. Is this right?
---- Decisions about treatment should never
be based on any vet's 'partial tear' or 'complete tear (rupture)' diagnosis. Going straight from diagnosing
an injury as a more severe ligament injury to a recommendation for surgery is not justifiable.
-- In the first place, the facts an exam
can determine about a dog's stifle's post-injury internal condition are limited. Although some vets commonly state
with apparent confidence that there is a complete rupture, this is a far-from-certain deduction on their part, rather than
a direct observation. They can't see ligaments on x-rays. They are making a guess about the ligament's condition based
on the post-injury looseness of the stifle.
-- More importantly, the stifle is a complex joint. The degree of damage
to the ligament is only one of a number of variables that influence whether a dog can re-stabilize the joint without
surgery. Whether or not the ligament is completely torn, a dog's ability to re-stabilize
the joint can be surprising. I receive a lot of emails about successful recoveries without surgery that followed vets'
assurances that there was a complete rupture of the ligament and surgery was the only choice.
---- With some other types of injuries, making
a decision for aggressive surgical treatment in a haze of uncertainty may be necessary because delay could cause harm, but
this is not one of those situations. With little risk involved in trying a non-surgical recovery, it is not wise to
rush to surgery based on any vet's estimate of the degree of the injury to the ligament. The careful restriction of Conservative
Management will act as the best possible diagnostic tool while it minimizes the risk of further injury. Improvement or a lack
of improvement over 8 weeks of careful restriction will tell you whether the dog needs surgery with far more certainty than
any vet can tell you based on a post-injury exam.
---- Also, I think it wise to bear in mind that while
there are many good, honest vets in the world, there are others who are trying to sell the highly profitable TPLO for every
dog who comes through their door. If a person sees a surgeon like that, the profiteering surgeon may say "Oh, well,
Fido has a complete tear, for sure! TPLO is absolutely necessary. We'd better schedule that now." Thereby
presenting his own interpretation of the degree of injury as proof-certain that the surgery he sells is required. This is
a sales tactic, not sound medical advice.
--- To be clear, it is true that dogs with a more severe ligament injury
are more likely to require surgery than dogs with a less severe injury. But each dog's injury is unique and the
only way to know if CM will work for a particular dog is to try the careful restriction of CM for that dog. What about high-energy, difficult to restrict dogs?---
Don't think that if your dog is difficult to restrict then surgery will be the answer. Careful restriction of activity
is the foundation of all dog ligament injury recoveries, whether or not surgery is necessary. Restriction is just as important
after surgery as in a non-surgical recovery. If a dog has surgery and is not kept from excessively active behavior for months
after surgery, the result can be disastrous.
--- It can be really difficult to restrict
some dogs. It is important to start out restriction with the resolution that the dog is going to be restricted properly. This
is no time to be a soft-heart who can't resist giving in to the dog's desire to run or play. Nor to take half measures
which allow excessive activity in some situations. Failure to restrict properly could result in terrible consequences for
--- It can be risky leaving a recovering
dog alone and loose in a large area including leaving the dog with the run of the house while his people are away. Sometimes
a dog will be very quiet for many hours but then some little noise or disturbance will set the dog off to go running back
and forth for a few minutes, possibly causing a re-injury. I dislike crates, and the idea that I hear many vets advance of
closing the dog in a bathroom or other very small room seems worse than a crate in some ways. But some means of limiting movement
is necessary. If there were no other way I would use a crate or a small room, but only as a last resort. First, I would consider
getting an ex-pen and setting it up wherever the family spends time in the house. There are a number of makers & sellers
of these ex-pens (or x-pens). The pens are generally constructed of 8 wire-mesh panels, each of which is two feet wide and
connected to the panels beside it with a hinged attachment. They come in various heights. An ex-pen is large enough to allow
the dog to move around freely and be comfortable, but not big enough to allow running, jumping, etc. I'd get the highest-sided
type and roof over the top with some cardboard or other material if the dog were likely to try a leaping escape. The big advantage
of an ex-pen is that the dog can see out and is right there in the place where the family lives. Not shut into a small room
staring at blank walls or confined to a crate barely big enough to turn around in.
--- Some very difficult dogs are going to
break down an ex-pen. They are going to need a more secure confinement. I would get a dog like that the biggest
fold-down cage I could find. I know these are made as large as 48 inches X 30 inches, and perhaps larger.
When dealing with a high-energy dog, I would also consider getting a brace. I usually suggest waiting a few weeks after starting
proper restriction to see how things go before ordering a brace. In most cases a brace is not necessary. But for high-energy,
very active dogs who are difficult to restrict, I think a brace is often a good idea. You are the best judge of whether your
dog is so difficult to restrict that ordering a brace immediately is appropriate. The brace helps with preventing potentially
damaging movements, but you still have to restrict the dog properly as best you can. The brace isn't 'instead of'
restriction. But for many dogs the fact of wearing the brace settles them down somewhat. They won't be as inclined to
try to run etc with the brace on. In this way the brace aids in the restriction. Braces aren't cheap. But well worth
the money in situations where a brace is helpful. There is a section on braces lower on this page.
--- I suggest that you not speak harshly to the dog for being too active, but instead physically prevent inappropriate
behavior without making any attempt at training the dog to not be excited and playful. Don't yell at the dog or say that
running & jumping around is bad. Just prevent the behavior with physical restraint. It may be possible to train a dog
to not be a bouncy, happy dog, but the chances are the dog will become depressed and just feel unloved. Much better to let
physical restraint do the restricting by getting down to hug / hold the too-bouncy dog, and by restraining with a cage or
a pen, and by using a leash with pull-preventing collar, blocking off stairs, etc. I would use methods like this to prevent
excessive stresses on the injured joint. Be loving toward the dog while using physical restraint to restrict activity appropriately.
Should the 8 weeks of original diagnostic restriction ever be extended? Or is
every dog who does not start to improve within the first 8 weeks in need of surgery?
--- Eight weeks should be seen as a guideline, not a hard-and-fast rule.
While most dogs will begin to show improvement within that 8 weeks unless they do need surgical intervention, some dogs will
take longer. Older dogs and dogs with other health issues or medications which could interfere with healing, for example.
Sometimes dogs for whom surgery is not a possibility for some reason will begin to improve after more than 8 weeks, showing
us that the 8 week mark is not firm. And in a few instances people have written me about young healthy dogs who showed
no sign of improvement at 8 weeks and were therefore scheduled for surgery but who then began improving while awaiting their
Since some dogs do begin showing improvement after more than 8 weeks, or show only minimal improvement at 8 weeks, I would
not disagree with anyone who wanted to wait longer before deciding surgery was appropriate for their dog, especially when
the dog was old or there were other reasons to expect a slow recovery. However, I think the great majority of dogs will
show some improvement by 8 weeks if they are going to be able to re-stabilize the joint. So a decision in favor of surgery
after 8 weeks without improvement would usually be appropriate.
--- Bear in mind that any setback re-injuries during the original 8 weeks put
you back at day one in counting the 8 weeks.
"My dog has improved well with Conservative Management, but his knee is larger than the knee of
the un-injured rear leg."
----- The method the dog's body uses to stabilize the joint after a ligament injury is to build
a buttress of tough scar tissue at the injured joint which prevents the bones from moving against each other inappropriately,
but allows most proper movement. This buttress development happens with recoveries after conventional surgery as well
as with non-surgical CM stabilization. The buttress can be seen and felt at the stifle joint. It is
especially apparent when the joint is compared to the other leg's stifle joint.
People seeing this enlargement may think it is something they should be concerned about, such as a swelling from inflammation.
But in fact it is normal, healthy tissue serving a useful purpose. Dogs who have had ligament injuries and have re-stabilized
the stifle joint will almost always have 'big knees' like this.
About Braces?---- Most dogs recover well without a brace, but sometimes a brace can be helpful. If a dog's
stifle is very badly damaged and unstable after injury, the new supporting tissue cannot get a start before there is re-injury
from even slight activity. In such cases a brace is appropriate. A brace can help support the injured stifle to prevent
further injury and hold the leg while new supporting tissue develops. Or in the case of a very energetic dog with whom
it is difficult to maintain restriction, or for very large or old dogs, a brace could be the best way to prevent repeated
re-injury during recovery. But bear in mind that a brace is not a substitute for proper restriction. You can't
put a brace on a dog and then let him run & jump. And remember that recovery from these injuries is expected to be slow.
If Fido is a little better and slowly continuing to improve after 8 weeks, he doesn't need a brace.
---- While a brace can be useful
for some dogs, you definitely should not rush to get a brace just because you want to do all you can to help Fido. Braces can be counterproductive. They are not good for all dogs with these injuries. You should wait a while after beginning restriction in almost all
cases to see how things go before considering ordering a brace. If Fido is improving with careful restriction, I would
not order a brace. But if he was showing no improvement, or had repeated re-injuries even though properly restricted,
I'd consider ordering a brace.
---- Many people who tell me they have used a brace for their
dog say they have been pleased with the braces, but others have not found the brace helpful. Some dogs will not
accept wearing a brace. People sometimes describe the braces as too cumbersome for their dog or in other ways not useful.
But if a dog is having an especially difficult time getting started on recovery, or repeatedly re-injuring the joint, a brace is definitely
---- You can find the websites
of dog brace makers with an internet search. There are several different types of braces. The kind I would very much
prefer would be like the ones made by 'Orthopets'. There are photos at their website:
There are other bracemakers who use the same method to custom fit a brace.
The bracemaker sends you a kit which you use to make a casting of Fido's leg. You send the casting to the bracemaker
and the brace is made. I do NOT recommend other types of braces which are made differently, by taking measurements of the leg or measurements from x-rays.
WARNING--- I have heard from a number of people that they contacted the Orthopets company about getting a brace and were referred to a vet in their area by Orthopets and those vets then insisted their dog needed surgery the vet would sell them before fitting a brace from Orthopets. In a number of instances the dog owners' description to me of the dogs' symptoms made it clear that surgery was not appropriate. Please be wary of this bait-and-switch type of scam. It is possible for vets to present themselves to bracemakers as willing to help fit braces, and then use referrals of dog owners from bracemakers to sell unneeded surgeries.
"Max, You advise waiting before deciding whether to get a brace.
Why not go ahead and use a brace from the beginning just in case it would help?"
The nature of braces is that they restrict movement. That is why we use
them, of course. But it is not possible to make a brace which prevents the movement we want to prevent while offering
no resistance to appropriate normal movement of the leg at the joint. This burdening of proper joint movement is something
we would rather avoid if possible. When the injury is severe the joint may be so loose that it requires a brace's
assistance to keep the bones in place while the new supporting tissue builds up. In that situation we must accept the
negative aspects of the brace along with the useful joint stabilization the brace provides. But most dogs show us by
improving with no brace (just careful restriction) that they are able to hold things together well enough to re-stabilize
without outside assistance from the brace. When a dog improves and slowly continues to improve without a brace and does
not repeatedly re-injure the joint, a brace would potentially be a detriment to recovery by preventing full proper movement
at the joint, or altering the contact between the bones disadvantageously, etc.
---- Also, the dog can't comment on the fit or action of the brace.
If you or I were wearing a brace, and there was a problem, we could say "At this point in the brace's movement
it seems to give me a little pain / seems to tighten up in its movement / pulls funny " or whatever, but the dog
can't do that. The dog is unable to adjust the brace or ask for adjustments or describe glitches in the brace's
working. So I believe it is better to not use a brace unless your dog undoubtedly needs one.
---- If I tried the recovery without a brace and my dog couldn't
get a start on re-stabilizing the stifle, I would certainly get a brace. Or if my dog was a super-active bouncing-off-the-walls
kind of dog who was at high risk of repeatedly re-injuring the joint, I'd go straight to a brace. But remember,
a brace is not a substitute for proper restriction. You must do your best to restrict properly so as to prevent
excessive stresses to the injured joint with or without a brace.
People love their dogs and want to do everything
they can to help their dogs recover. This makes it tempting to buy things which it is hoped will help. But it
is easy to do harm with the best of intentions. Don't buy your dog a brace to make yourself feel better.
If Fido's situation fits the description above of when a brace is appropriate, get Fido a brace. It he is slowly
improving, don't get a brace.
About Dog "Wheelchairs"? Dog 'wheelchairs' are very seldom appropriate for dogs with this kind of injury. Please just follow the suggestions for activity control which avoids all running and jumping but allows gentle activities. Gentle use of the injured leg is part of the process of recovery. As time passes and Fido becomes willing to bear weight on the leg, we want him to gently do so. We don't want the leg immobilized. There are rare situations in which a "wheelchair" type device would be appropriate, so I don't want to say "Never", but very very seldom do circumstances make a 'wheelchair' appropriate for a CCL(ACL) injury recovery.
What About Elastic Wraps?
Vetrap; Coban; Ace; etc elastic wrap-type bandages:
An elastic bandage wrap could perhaps be a good thing on your own injured joint,
but there are serious potential problems with using an elastic wrap on a dog. It has to be pretty tight to do any good,
but if it is a little too tight it cuts off the blood to/from the lower leg. If you or I have it too tight on ourselves
we can feel that it is too tight and re-do the wrap more loosely so it is OK. But used on a dog, the dog can't
tell you the wrap is too tight. So it is possible to do serious damage from cutting off the circulation.
---- I advise you not to
use a wrap. The potential for making it too tight and doing serious harm is too great.
Emptying Bladder &
---- Be sure that your dog has plenty of opportunities. If she
can walk on her own, that is fine, but don't rush her. Let her move at her own pace. If she cannot walk on
her own, or needs assistance, help her with a towel-sling. (Towel-slings are described lower on this page under the
heading 'Stairs'). Take her out regularly. Don't just wait for her to tell you she wants to go out.
Be sure she has clean fresh water easily available to her at all times.
---- The 'gastro-intestinal reflex'
is simply the tendency to feel an urge to defecate(poop) shortly after swallowing something. The practical use of this
is to give a dog a treat just before going out when you hope the dog will have a bowel movement. And to always take
a dog out right after a meal.
---- It is usually better not to try
to be helpful to the dog by holding her up while she tries to squat to pee or position herself to take a dump. Most dogs
are sensitive about being interfered with while they are emptying bladder or bowel. Let the dog work out the
best way to position herself. She will take time to figure out how to do this, but almost all dogs will manage best
alone working this out for themselves. If she needs to be carried out or supported with a towel-sling to get outside,
once there leave her alone standing in an appropriate location. Don't watch her directly since that is also often
off-putting for dogs. Watch her out of the corner of your eye while you face in another direction examining the tree
leaves, the clouds, whatever. Don't rush her. Praise her for successful completion of the task!
If she cannot stand at all due to bilateral severe injury, you will have to encourage her soothingly while holding her in
an appropriate position using your towel sling or perhaps just your hands. It will probably take some time to work out
a way to do this that she will be comfortable enough with to relax and get the job done. Be patient.
Slippery Floors? ----A slippery floor is a hazard to a dog who is trying to
recover from a ligament injury. Just like you or I, when a dog slips he will automatically try to recover from the slip
with a quick move of whatever limb is likely to save him from falling. This can be the injured limb, and this can cause
a further injury. The dog needs a floor he can walk on without his paws slipping. If you have floors that your dog could slip
on, you need to do something to make footing more secure for him. Rubber-backed scatter rugs are one option.
---- Here is another method
which some will find too extreme, but it is very effective: Dissolve a cup of sugar in a bucket of warm water and mop the
floor with it. Allow it to dry and the floor will be slightly sticky. The stickiness will adhere a small layer of dust and
the floor will no longer be slippery.
Going up stairs puts more stress on a dog's rear
legs. A sling made from a towel is a very good way to handle going up stairs. Just loop the towel
under the Fido's belly so you have both ends above his back and can lift up to provide some support for his rear. Then walk beside him and pull
up on the towel, taking some of the weight off his rear legs. You don't want to lift his
rear end into the air so that his paws don't touch the floor. Just take a good bit of the weight off those rear legs. What we are aiming for is not that there be no weight supported by Fido's rear legs. We want less weight supported by his rear legs. We do not want Fido's butt up in the air with his rear legs dangling. Going down stairs shifts a dog's weight forward
so you won't need the sling, and Fido will have better control going down stairs without the sling.
---- You and Fido are going to need to learn to use the belly-sling together. Start out learning on level floor. Place the towel under Fido's belly without lifting up as you hold the ends of the towel above his back. Praise him for accepting the towel being there. Now tempt him with a treat to walk forward a step with the towel in place, and praise him for doing that and give him the treat. Next lift up just a very little bit as you hold out another treat in front of him to tempt him to walk forward a step with the towel putting a little upward pressure on his belly. More praise! Another treat! Next walk a few more steps with the towel lifting up a little more. Next try without the treats. Move the towel-ends you are holding over Fido's back forward as you say "Here we
go!" or whatever Fido will recognize as indicating forward movement. Don't just stand there expecting
Fido to understand what that towel is all about and that you want him to start walking forward. You need to let Fido know
what you expect him to do. Your moving forward as you lift a little with the towel-sling moving his butt forward will cause him to step
forward himself with his front paws. As he first moves forward with the towel-sling in place, tell him "Good! That's right! Here we go!"
to encourage him and he will soon catch on to the idea. After you practice using the towel-sling on a flat surface, you and Fido will be ready to climb stairs using it. Remember that the towel-sling is for going UP stairs. NOT for going down stairs. Fido's weight will be mostly on his front legs when going down stairs and he won't need the extra support. The towel-sling could cause him problems when going down stairs. Use the towel-sling ONLY for going UP stairs or if Fido needs help walking in other situations. NOT for going down stairs.
Very often dogs' leg muscles shrink markedly in size after the injury and during
the early weeks of recovery. This happens because the muscles are not being used. Don't be too worried. What
the dog needs first of all is to regain stability in the stifle. Once he can feel that the stifle is stable he will
go back to using the leg more and more and the muscle will build back up naturally. You couldn't stop it if you
wanted to. Sometimes people are too anxious about the muscle because they see it has reduced in size and they want to
do something about that. They start doing too much weight-bearing exercise too soon which results in a less-than-optimum
recovery for the stifle. I think the right approach is to just make the stifle your priority and the muscle mass and
strength will return when the stifle is restored to its stable state. Using swimming as therapy will help minimize muscle
atrophy without undue risk of furthering the injury.
Pulling at leash?
a dog is pulling on the leash that is not good. I would want to prevent pulling at the leash since that is putting much
more pressure on the stifle joints than would be there if the dog were not pulling. I hear good things about a kind
of head harness that prevents pulling by redirecting the pulling force. One brand is "Gentle Leader". Another
Adequan Injections? --- Another thing you might want to consider is a series of Adequan injections.
Sometimes Adequan seems helpful and with other dogs it doesn't seem to make any difference. Adequan is a 'polysulfated glycosaminoglycan'. They market this as an arthritis treatment, but it also can possibly be useful in situations where joint damage has occurred and the dog's body is in the process of repairing
and maintaining the damaged joint. The injections are given twice a week for 4 weeks, intramuscularly. This is easy
enough to do. You can probably do it yourself. You do need a prescription to get Adequan in the United States,
but if your vet is a reasonable person he will give you the prescription. Before asking him, figure out how much you
need and research the different on-line vet medication supply dealers for price.
---- Horse people use a lot of Adequan so the horse-focused
suppliers are likely to have it and be competing with each other on price.
There are three different Adequan products:
-- Equine, for horses;
-- Canine, for dogs;
-- and a special type intended to be injected
directly into the joint. You don't want that one.
You want one which is injected intramuscularly. I believe the
only difference between equine & canine Adequan is that the canine has a small amount of preservative added to it since
the whole vial will probably not be used at once. Adequan
comes in a 2-pack of 5mL vials. At the time of this writing, this series of injections, done at home, would cost around
$100 total for the 8 injections for a 62 pound dog (.02mL per pound per injection, Fido = 62 lbs, so 1.24mL per injection
times 8 equals 9.92 mL, almost exactly 2 vials). When you find the best price on-line, call or go see your vet.
Tell him you'd like to try a series of Adequan injections for Fido. The vet probably can't match the best on-line
price, but I'd buy the Adequan from him if he would come close to the price I found on-line. If he
can't get close enough to the on-line price, ask him to write you a prescription so you can get the Adequan on-line. A
vet who is trying to maximize his own income may refuse to do this and insist that he needs you to come into his office for
him to give the injections. This would be a red flag that you need to find another vet who will work with you to minimize
---- Cartrophen? Cartrophen is very similar to
Adequan. Adequan is sold in the US. Cartrophen is sold in Australia, Canada, the UK, and other places. I
like both Adequan and Cartrophen. However, there is a potential for confusion since the generic name of Rimadyl, a NSAID
drug, is very close to the name Cartrophen. Rimadyl is Carprofen. Since Carprofen (Rimadyl) is also prescribed
for joints, there is a risk of a misunderstanding. Except for short-term limited situations, I advise against the use
of Carprofen (Rimadyl)for the reasons explained above under 'Pain Medication? Inflammation Reducing Medication?
Improvement Slows or Stops?
"My dog was slowly improving but
after about 12 weeks he seems to be staying about the same for a couple of weeks now."
A dog may improve nicely for a few months,
then improvement seems to slow or stop. If this is the case, first try reducing activity
for a few weeks to see if you might have moved ahead too fast and need to cut back so that improvement can resume. If
this reduced activity does result in improvement re-starting, then the previous level of activity was too-much-too-soon. But often improvement slows after the first few months and thereafter proceeds at a slower pace.
How Close To Full Pre-Injury Ability Is Achievable?
---- All dogs eventually reach a point
in recovery where the joint is as good as it is going to get. Whether or not surgery is part of recovery, only a small
proportion of dogs recover to near pre-injury capability. The joint, once damaged, is probably never going to be all
that it was before the injury. On average probably about 85% of ability is recovered.
---- The best thing you can do for your dog
after recovery is to avoid activities that cause limping or other symptoms which indicate the joint is being pressed beyond
its limits. For example, perhaps pre-injury the dog could go for 10 mile hikes, but now he limps after 5 miles.
You need to make walks less than 5 miles.
---- Avoid excessive activity or any high-stress activity which causes symptoms
to resume, and give your dog plenty of joint support supplements glucosamine & chondroitin, and he will have the best
possible joints for a long and active life.
Sometimes vets promote TPLOs by saying that after recovery from this surgery the dogs will be able to engage in high-stress
sports without trouble. This is only TPLO sales-promotion talk. Dogs who have had TPLOs need to avoid high-stress
activity. They are especially at risk for tibial tuberosity fracturing and should avoid any activity which involves
impact stresses. Re-Injury Months After Conventional Surgery Done With Nylon Monofilament Ortho Suture?
sometimes happens that a dog who has had a conventional surgical stabilization (usually done with 80lb monofilament ortho-suture)
will have symptoms recur after some months have passed and recovery has been going well.
---- It always happens that the monofilament will eventually stretch
or break. How long this takes depends on the dog's size and activity. Usually before the ortho-suture fails
the joint will have built-up sufficient new stabilizing scar tissue so that the loss of the stabilizing influence of the monofilament
will not result in a big problem. If there is a recurrence of symptoms of stifle instability, the symptoms will usually
not be severe since the joint now has new scar tissue support. But it doesn't have full support yet. Careful
restriction begun when you see limping will give the joint the conditions it needs to further develop the tough fibrous
scar tissue stabilization. This scar tissue development will happen slowly, over the course of several months.
I would treat a re-injury which occurred months after surgery with careful restriction, just like a new injury.
---- However, in a minority of instances it is possible that a piece
of the broken monofilament may intrude into a place where it causes trouble. If that happens it will need to be removed.
Or the dog may not be able to successfully restore stability on his own for some reason. Then surgery may be needed.
But certainly I would expect most dogs to do well without surgery after this kind of post-conventional-surgical-recovery
renewal of symptoms. It would not be wise to rush to surgery before first trying 8 weeks of careful restriction.
---- Re-injuries can occur to dogs who have recovered non-surgically
too. In all these situations the best first choice is restricting activity carefully just as you would for a new ligament
---- Some vets want to sell
TPLOs or TTAs to people whose dogs have had a re-injury after conventional surgery. I would be strongly opposed to either
TPLO or TTA in most such cases. If your dog has this kind of problem, and it turns out that your dog cannot improve
when carefully restricted, I would want a new surgery to be some form of the conventional LSS stabilization in most cases.
---- It could happen that the joint does not need stabilizing surgery
but does need to have suture debris from the original surgery removed.
---- Dogs who have re-injuries are often dogs whose restriction wasn't maintained
long enough or seriously enough.
How long is this recovery going to take?
---- Whatever the treatment method, remember
that recovery from these ligament injuries is slow, and that months after recovery seems complete the stifle will still be
vulnerable to re-injury from too much stress. Oftentimes vets who are trying to convince people that the surgery they
are recommending is preferable will tell them that recovery is quick after the surgery. It is true that some weight-bearing
is often seen more rapidly in the period just after TPLO or other surgery. But that is only the very beginning of recovery,
not a long-term successful result.
---- A few years ago I interviewed roofing contractors about putting a new roof on my house. Several boasted
that they would have the new roof on in a very short time. But what I wanted was the best roof, not the roof that went
on the fastest. If TPLO surgery will have a dog bearing weight on the leg in the shortest time, is it therefore the
best choice? No, because we want our dogs to have the best long-term recovery, not the fastest time to the first step
in the recovery process.
That joint is going to be the
weak link in the dog's leg's ability to handle stresses for a long time to come, whether or not surgery was part of
his recovery. Return to normal activity should be accomplished very slowly and cautiously over a number of months.
Activities involving jumping and landing
with twisting movement, such as catching things in the air, or other very high-stress-to-the-stifles activities, should be
avoided forever, regardless of treatment option chosen.