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Veterinary Practice News Editorial Blog:
Monday, July 26, 2010
10 Deadly Sins of Untreated ACLs
By Phil Zeltzman, DVM, Dipl. ACVS
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Severe DJD in the knee of Bravo, a German shepherd with a chronic ACL tear addressed with a TPLO. Photo courtesy of Phil Zeltzman, DVM, Dipl. ACVS | Clients sometimes ask what would happen if we didn’t address a torn anterior cruciate ligament. Some colleagues suggest conservative treatment as a perfectly valid option.
A non-surgeon colleague even wrote elsewhere that since people sometimes don’t need surgery for an ACL tear, then we shouldn’t need it in dogs. With all due respect, this shows a basic misunderstanding of the differences in functional anatomy between dogs and humans.
How many reasonable, objective, ethical, honest reasons can you find to recommend conservative treatment as opposed to surgery?
Let’s go over 10 possible consequences of an ACL rupture treated conservatively.
- Pain. Patients with an acutely torn ACL are classically in pain. When the tear becomes chronic, pain may subside to some degree, but it stills hurts.
. - Degenerative joint disease (DJD). We routinely notice during surgery that patients with long-standing ACL tears have more DJD than patients with an acute injury. This in turn leads to pain.
. - Fibrosis. This is what we rely on when we recommend conservative treatment for an ACL tear. Experience proves that it is not enough to provide good function, at least in large dogs. In turn, fibrosis leads to our next point.
. - Decreased range of motion. Long term, a likely consequence of DJD and fibrosis is a decreased range of motion of the stifle.
. - Muscle atrophy. Patients who favor a hind leg classically show various degrees of muscle atrophy.
. - Exercise intolerance or poor athletic performance. Obviously, it’s tough to run around with a sore knee, whether you’re a family pet or a working dog.
. - Contralateral ACL tear. Arguably, weight shifting may lead to a tear of the opposite ACL. While this may be manageable in a Yorkie or a cocker, it becomes a much bigger problem with a Labrador or a mastiff. I am aware that a recent article seems to disprove this argument, but it doesn’t seem to match what we see in everyday practice.
. - Meniscal tear. The instability in the knee can lead to a tear of the medial meniscus, causing even more pain.
. - Weight gain. A consequence of many of the above changes is decreased activity, which will likely cause weight gain.
. - Distant problems. The changes in gait and posture can affect all three other limbs, as well as the spine.
In fact, one could argue that some of these changes can almost be used to “date” the ACL tear. Let’s think about it:
- A patient with an acute ACL tear is classically lame and painful.
- A patient with a chronic ACL tear typically presents limping, possibly less painful, with a significant amount of DJD, a decreased range of motion, muscle atrophy and weight gain.
From a surgeon’s standpoint, an ACL is a very fixable problem.
“From a functional point of view, an ACL rupture is the beginning of a cascade of events in other body parts (joints, muscles) that we can’t forget,” explains Laurie McCauley, DVM, CCRT, a rehabilitation specialist and owner of TOPS Veterinary Rehabilitation in Grayslake, Ill.
Sure, it is perfectly possible to live with a torn ACL. Certainly, it may be the only option when the clients absolutely cannot afford surgery.
But it’s hard for me to believe that affected dogs, especially large ones, have (and will have) a good quality of life.
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