Dog Torn ACL Treatment Without Surgery: A Rehab Vet’s Approach

After the diagnosis of their dog’s torn ACL, treatment without surgery is something that many dog parents ask their veterinarian about. To thoroughly address the topic, integrative veterinarian Dr. Julie Buzby brought in an expert—board-certified rehabilitation veterinarian Dr. Britt Carr Benson. Dr. Carr Benson provides the background information on ACL tears in dogs and then discusses seven ways to help a torn ACL heal without surgery.

Meet Tumbles

One of my rehab patients, Tumbles, is a 10-year-old male neutered mixed breed dog. He was an avid ball-chaser and swimmer before coming up lame in his right hind leg after chasing a squirrel in the yard. His family veterinarian diagnosed him with a right cranial cruciate ligament (CCL) injury (the dog version of an ACL injury in humans) and discussed surgery to treat the cruciate ligament tear.

However, Tumbles was previously diagnosed with a heart condition that made anesthesia extremely risky. Understandably, his owners were quite nervous about doing surgery, so they decided to look into the options for non-surgical treatment of his torn CCL.

What is the cranial cruciate ligament (CCL) in a dog?

The cranial cruciate ligament (CCL) in a dog is synonymous to the anterior cruciate ligament (ACL) in a human. The CCL is one of the ligaments that connects the femur (i.e. thigh bone) to the tibia (i.e. shin bone) and stabilizes the stifle (i.e. knee) joint during movement and stance.

What causes CCL injuries in dogs?

Although the knee joint in dogs is similar to ours, the forces applied to the joint during weight bearing are vastly different. Our hip, knee, and ankle joints are perpendicular to our weight bearing surface—our feet. When we stand, there is minimal stress to the ligaments in our knee.

Dogs, however, stand on their toes with the ankle elevated and the knee forward. This places more stress on the ligaments, especially the CCL. Dogs also have a very steep slope to the tibia (i.e. shin bone) whereas humans have a very flat top to the tibia. This difference places additional stress on the CCL, as its job is to prevent the femur (i.e. thigh bone) from sliding down the steep slope of the tibia. All this to say, the CCL works very hard to keep the knee stable during movement and standing! 

CCL injuries in dogs vs ACL injuries in humans

The other difference between humans and dogs is that in humans, ACL injuries tend to be traumatic. Often you hear of athletes who injure their ACL during sports or a person with a torn ligament after a fall or accident of some sort. 

In dogs this can sometimes be the case too. However, more often, dogs suffer this injury as the result of degeneration or weakening of the ligament. We don’t always know why this happens, but over time, the CCL can slowly weaken. And eventually the cruciate ligament sustains a partial tear or a complete tear. This is thought to be how most torn ACLs in dogs occur.

Predisposing factors for a cruciate ligament tear in dogs are:

• Obesity
• Genetics
• Breed (predisposed breeds include: Rottweiler, Newfoundland, Staffordshire Terrier, Mastiff, Akita, Saint Bernard, Chesapeake Bay Retriever, and Labrador Retriever)

Studies have shown that this is the most common hind limb injury in a dog. And they have also demonstrated that up to 66% of dogs will tear the CCL in the other knee within two years of tearing the first CCL.

How do you treat a CCL injury in dogs?

There are two major categories of treatment for CCL injury in the dog—surgical treatment and non-surgical management. The gold standard treatment for cruciate tears in dogs is surgery. Common surgical options include tibial plateau leveling osteotomy (TPLO surgery for dogs), tibial tuberosity advancement (TTA), extracapsular lateral suture stabilization (ELSS), and CORA Based Leveling Osteotomy (CBLO). Multiple studies have reported superior outcomes in dogs who underwent surgery for an CCL injury versus those who didn’t. 

While this is widely known and accepted, there is still a large population of dogs who cannot undergo surgery for various reasons. Medical contraindications, financial concerns, or other dog-related or owner-related factors may all make surgery a less favorable option. For these dogs, it is necessary to explore alternatives to surgery.

How does non-surgical treatment compare to surgery?

A recent study compared surgical treatment and non-surgical management for CCL injury in dogs. Surgical treatment was found to be superior. But the study indicated that a conservative approach, including non-steroidal anti-inflammatory drugs, weight loss, and physical therapy, may yield successful outcomes in approximately two-thirds of patients one year after CCL rupture.

Often, many different interventions aimed at reducing pain and inflammation make up the non-surgical management plan. The goal is to improve comfort, function, and quality of life. Treatment of a CCL injury without surgery can be comprised of some, or all, of the following options:

• Activity modification
• Weight management
• Medications to reduce pain and inflammation
• Nutraceuticals
• Rehabilitation therapy
• Intra-articular therapies
• Stifle orthotic (knee brace)

7 Ways to treat a dog’s torn ACL without surgery

#1. Activity modification

Activity modification is one of the most important aspects of non-surgical management of a CCL injury. The first 8 to 12 weeks following the injury are the most critical for activity restriction. During this time, the body is trying to place scar tissue around the knee joint to stabilize it, as well as reduce inflammation and swelling within the knee.

No amount of scar tissue will ever fully stabilize the knee joint, and the body will never be able to heal or regenerate a torn CCL. But placing scar tissue around the knee will help to reduce instability within the knee. 

During the first 8 to 12 weeks, it is important to not allow your dog to run, jump, play roughly, or have off-leash time in the yard. Encourage your dog to rest and confine him or her when left unattended. Avoid letting your dog walk on slippery surfaces and assist your dog when doing stairs. (Stairs should be performed sparingly if possible as your dog recovers.)

After the initial 8 to 12 weeks, dogs should gradually return to low-impact activity. Walks within their comfort are encouraged. However, you should avoid high-impact activities such as squirrel chasing, playing fetch, and running. And try to limit climbing stairs and jumping on and off furniture. 

Helpful tips

After a CCL tear, do your best to avoid letting your dog walk on slippery surfaces. If this isn’t possible, place throw rugs or yoga mats on the ground as a temporary solution. Or, for an option that provides traction and goes everywhere your dog goes, apply Dr. Buzby’s ToeGrips® dog nail grips. 

Additionally, providing your dog with an orthopedic foam bed can give more support and comfort while he or she is sleeping or resting.

#2: Weight management

Weight management is essential to the success of conservative treatment for a torn cruciate ligament. Since dogs with a CCL injury are on restricted activity, you should consult with your veterinarian about how to modify your dog’s diet to avoid weight gain.

Also, if your dog is overweight, it is imperative that he or she loses weight and maintains a lean body weight. Less weight will result in less force on the joint, which will improve function and comfort. Diet is a crucial part of helping your dog lose weight. It can be useful to ask your veterinarian to calculate your dog’s ideal caloric intake for weight loss and maintenance. And the vet can also help determine when your dog is ready to resume low-impact activity, which will also help with maintaining a healthy weight.

#3: Medications to reduce pain and inflammation

Your veterinarian will prescribe various medications to help reduce inflammation and improve comfort initially, as well as long-term. Often, he or she will also recommend using other conservative management strategies at the same time. This can help reduce the dose or frequency of medication needed to keep your dog comfortable.

Based on your dog’s overall health, injury, and pain level, your vet will decide which medication or medications are going to be best for your dog. And he or she will discuss the benefits and possible adverse effects of each medication with you too.

Some possible medications include:

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as Rimadyl® (carprofen for dogs), Galliprant® (grapiprant), Metacam® (meloxicam), Previcox® (firocoxib), and Deramaxx® (deracoxib)
• Gabapentin for dogs

If you notice any side effects from the medications, please notify your veterinarian promptly. Also, keep in mind that if your dog is on daily medications, your vet may recommend blood work every 6 to 12 months to ensure your dog is tolerating the medication well. 

#4: Nutraceuticals

Nutraceuticals (e.g. joint supplements for dogs) are often used to help reduce joint inflammation and slow the progression of osteoarthritis in dogs. There are multiple commercially-available joint supplements for dogs, which can make it difficult for dog owners to choose one. However, your veterinarian can help you figure out which joint supplement will be best for your dog.

The ideal joint supplement should have demonstrated efficacy and bioavailability, and ideally have in vivo testing (i.e. testing in animals) with a randomized clinical trial. There should also be quality assurance with a third-party laboratory. 

Components that have been shown to reduce inflammation associated with osteoarthritis include:

• Glucosamine/chondroitin sulfate joint supplements
• Omega-3 fatty acids for dogs supplements
• Methylsulfonylmethane (MSM)
• Curcumin longa extract
• Boswellia serrata extract
• Green lipped mussel for dogs
• Egg shell membrane

There are multiple options available, including Dr. Buzby’s Encore Mobility™ hip and joint supplement, Dasuquin® Advanced + ESM, Phycox® Max, Movoflex®, Glycoflex®, YuMOVE®, Flexadin® Advanced, Antinol®, and Welactin® Advanced. Your veterinarian will recommend the best option for your dog’s situation. 

#5: Rehabilitation therapy

Rehabilitation therapy is often recommended to help reduce inflammation and swelling and improve range of motion, comfort, and function. This typically involves working with a provider certified in rehabilitation therapy for dogs and cats. The rehabilitation therapist often performs therapies in-clinic in addition to recommending an at-home exercise program that you can do with your dog.

Therapies that can help manage CCL injury are:

• Manual/massage therapy
• Low level laser therapy for dogs
• Extracorporeal shockwave therapy
• Therapeutic ultrasound
• Transcutaneous electrical nerve stimulation (TENS)
• Pulsed electromagnetic field therapy (PEMF for dogs)
• Therapeutic exercise
• Hydrotherapy (underwater treadmill for dogs or swimming)

The rehabilitation therapist will decide which therapies will be best for your dog. Dogs often receive rehabilitation therapy weekly for the first 12 weeks. Then the therapist may recommend spacing out the scheduled appointments for the maintenance phase.

#6: Intra-articular therapies

The veterinarian or rehabilitation therapist may recommend intra-articular therapies (i.e. joint injections) to help reduce inflammation within the joint and improve overall comfort. There are multiple options available for dogs, including:

• Hyaluronic acid (HA)
• Platelet rich plasma (PRP for dogs)
• Stem cell/PRP therapy
• Cortisone (steroid)

Your veterinarian will determine if your dog is a candidate for intra-articular therapies, and if so, which type of joint injection will be best.

#7: Stifle orthotic (knee brace)

While there are multiple commercially-available dog ACL braces, few have been scientifically proven to help. The braces that have been scientifically validated are custom, hinged stifle orthotics—ones that an orthotist made specifically for the dog.

To make a custom, hinged stifle orthotic, a veterinarian or rehabilitation therapist will make casting of the affected limb. Then he or she will send the casting to the orthotist, who makes a mold of the limb from the cast. After making the mold of the limb, the orthotist builds a knee brace specifically for the limb.

Then he or she sends the knee brace back to the veterinarian or rehabilitation therapist for fitting. Once your dog is fit for the brace, he or she will wear the brace intermittently over the next couple of weeks while he or she becomes accustomed to it. But ultimately your dog should wear the stifle brace any time he or she is active. And then you can remove it when your dog is at rest. 

Common complications of a knee brace include rub sores, slipping, and improper fit. Also, it is important to know that dogs with knee braces may benefit from rehabilitation therapy to help them maintain muscle mass. 

Your veterinarian or rehabilitation therapist will determine if your dog is a good candidate for a knee brace.

Tumbles’ success story

Tumbles’ veterinarian recommended activity modifications, prescribed a non-steroidal anti-inflammatory drug, calculated a calorie count to help him maintain a healthy weight, and referred him to me for rehabilitation therapy. I started him on weekly manual/massage therapy, low level laser therapy for his knee, therapeutic exercise, and a home exercise program. 

Four weeks into rehabilitation therapy, I added underwater treadmill therapy to his therapy program. At this point, he was comfortable enough that he was just taking the NSAID as needed.

Then at 12 weeks, Tumbles’ veterinarian and I cleared him to resume low-impact activity. And he moved to once-monthly rehabilitation therapy appointments. We discussed avoiding squirrel chasing and chasing the ball. However, we did encourage Tumbles to swim and take short walks as long as he remained comfortable

At 16 weeks, Tumbles transitioned from underwater treadmill therapy to swimming for short periods of time under my vigilant supervision. His owners had a pool, and they were able to carefully restart short periods of swimming at home three times per week. On the days he wasn’t swimming, Tumbles would participate in short leash walks within his comfort.

At 6 months following his injury, Tumble’s owners reported they were very pleased with his outcome and level of comfort and function at home!

Note from Dr. Buzby

I hope this article from Dr. Carr Benson gave you hope and equipped you with the information you need to advocate for your dog. While l still firmly believe that surgery is the gold standard treatment for ACL tears, the interventions Dr. Carr Benson discussed can make a huge difference for your dog’s comfort and recovery in cases where surgery isn’t an option.

About the author

Dr. Britt Carr Benson is a diplomate of the American College of Veterinary Sports Medicine and Rehabilitation. She earned her Bachelor of Science in biology from Furman University in Greenville, South Carolina. She then attended the Virginia-Maryland College of Veterinary Medicine at Virginia Tech in Blacksburg, Virginia.

After earning her Doctor of Veterinary Medicine, Dr. Carr Benson completed a small animal rotating internship at the Animal Specialty Group in Los Angeles, California followed by a small animal surgery and sports medicine internship at Veterinary Orthopedic and Sports Medicine Group (VOSM) in Maryland. She then remained at VOSM to complete a residency in canine sports medicine and rehabilitation. During her residency, Dr. Carr Benson attended the Canine Rehabilitation Institute and is also a Certified Canine Rehabilitation Therapist.

She has co-authored dozens of peer-reviewed publications and several textbook chapters. She is a national speaker and instructor as well as a recipient of many awards and honors for her work.

If you decided to treat your dog’s torn ACL without surgery, how did he or she do?

Please share your experiences below.