Bindo, a small mixed-breed dog, receives electroacupuncture to the left hind limb for medial patellar luxation. Photo courtesy Dr. Adrianna M. Sage With all the strides integrative rehabilitation and physical medicine (IRPM) have made over the past two decades, why does offering that instead of surgery for orthopedic problems continue to seem so “radical”? Especially for conditions that do not constitute orthopedic emergencies, animals have time to wait and begin a round or two of rehabilitation first. The often-touted argument, without surgery, dogs with cranial cruciate ligament disease will develop more arthritis than with it lacks evidential justification. Given the breadth of modalities that IRPM encompasses, it behooves veterinary practitioners to provide clients with a full complement of options, surgical and non-surgical, and risks and benefits for each pathway, well before making that first cut. Patellar luxation (PL) is not an emergency, either. In fact, for many of these dogs, the problem is not just the patella and the groove in which it travels. PL results from an imbalance of soft-tissue forces and, often, a deficit in intrinsic support. However, the issue may have started elsewhere, such as the hip. If we analyze the anatomic connections to the patella and their fascial extensions, it becomes clear deepening the trochlear groove and fastening down fascia targets only a part of the problem. To fully comprehend the underlying causes and subsequent consequences, we must examine the entire dog. A luxating patella causes pain, anxiety, weight shifts, myofascial strain, and various patterns of tension throughout the body. In short, there’s a lot we need to unpack and undo. Nonsurgical treatment “Conservative” management, now broadened into full-spectrum IRPM methodology, comprises far more than it used to, when it consisted merely of NSAIDs, a few therapeutic exercises, weight control, and massage. Modern-day modalities include acupuncture, electrotherapy, shockwave therapy, pulsed electromagnetic field therapy, kinesiology taping, underwater treadmill, medical massage, fascial release, trigger point therapy, stretching, cannabinoids, injectable agents, thermal treatments, and more. Why haven’t we heard more about IRPM for PL? In this author’s opinion, veterinary medicine, especially as taught in many veterinary colleges, contains an intrinsic bias toward surgery. Students learn about PL mostly during orthopedic surgery classes and rotations. Their orthopedic surgery instructors may be more likely to encourage surgery first rather than IRPM because they are more familiar with the former. Some may have little to no knowledge of current rehab techniques or even have a bias against them. It may, therefore, be inconceivable to them that non-surgical treatment could be successful, scientific, or in any way superior to surgical techniques. Not all dogs get sent for surgery, at least not right away. According to one group of authors, “Surgical treatments are recommended for dogs with an intermittent or permanent lameness as a result of patellar luxation or in young dogs in an attempt to mitigate the negative effects of the condition on growing bone.” They continue: “Joint pathology increases with age and luxation grade, and surgical correction should be performed at the earliest opportunity to limit further development of skeletal abnormalities of DJD.”1 With this extensive range of inclusion criteria, who does it leave out? Pretty much no one. Even the lowest-grade dogs will usually show intermittent lameness. Risks and complications of surgery The risks and complications from surgical correction of PL range from the more common (post-surgical pain, infection, bleeding, and adverse reactions to anesthesia) to the less frequent (implant failure, persistent lameness, arthritis, and reduced range of motion of the stifle). Even after surgery, PL may recur, especially for dogs with higher-grade luxation. Out of 24 dogs and 29 stifle joints in dogs that underwent surgical correction of grade IV medial PL, “24 percent of stifle joints had major complications, and 21 percent of joints required surgical revision. Grade II to IC recurrence of MPL was identified in 21 percent of stifle joints. One dog had a catastrophic complication requiring limb amputation.”2 Another group noted, “The overall complication rate following stabilization of unilateral patellar luxation has been reported as 13 to 45 percent, including all the surgical correction(s) for different medial patellar luxation grades.”3 Dogs are never the same after surgery. Severing skin, muscle, fascia, and bone permanently disrupts bodily integrity, as well as the fascial support mechanisms and force vectors. In comparison, IRPM works to restore bodily function to a better working state by changing muscle tone, releasing fascial restrictions, improving neural communication, and facilitating the healthful flow of blood and lymph. How is IRPM different? The risks of IRPM are minimal compared to surgery. IRPM is also more cost-effective than surgery, especially when factoring in pre-operative laboratory tests, hospitalization, and possible post-surgical care procedures or additional surgery to address complications that may arise. Nonsurgical management causes less stress and allows dogs to remain in familiar surroundings without hospitalization. While some clinic visits may be necessary for modalities such as underwater treadmill therapy, extracorporeal shockwave therapy, and medical acupuncture, clients can work on prescribed therapeutic exercises directly with their dog and even perform gentle massage, stretching, and photomedicine. When assembling an IRPM treatment plan, we tackle the same issues surgeons do. To wit, “Reconstructions are usually performed to release tight tissues and tighten loose tissues.”4 IRPM seeks to do the same, but from a physiologic approach (e.g. mobilizing fascia, relaxing muscles, and modulating nervous system activity). In contrast, soft tissue surgical procedures for medial patellar luxation include “medial desmotomy, lateral imbrication, antirotational sutures, and release of medial musculature.”5 “Medial desmotomy refers to a releasing incision in the soft tissues on the medial side of the joint, including the medial retinaculum and joint capsule. Desmotomy allows (the) release of contracted tissues that prevent the patella from returning to the trochlear groove. The releasing incision, including the joint capsulotomy, (is) left open. Leakage of synovial fluid is not a problem.”6 “Lateral imbrication goes hand in hand with desmotomy in most cases, as it involves the use of “gathering sutures” to tighten up soft tissues contralateral to the luxation.”7 “Antirotational sutures are similar to the extracapsular sutures used for repair of the cranial cruciate ligament.”8 “Muscle release procedures can be accomplished in a variety of ways. The rectus femoris muscle can be dissected away from the joint capsule and the adjacent femur and musculature as an extension of the medial desmotomy. Freeing the rectus femoris muscle, at least to the level of the middle of the femur, may relieve significant medially directed tension on the patella.”9 Adrianna M. Sage, DVM, MS, cVMA, DACVAA, applies electroacupuncture to Bindo’s medial pelvic limb to address myofascial restriction that is inciting the luxation. Photo courtesy Dr. Adrianna M. Sage A closer look at both options Even without considering the impact of invasive maneuvers, such as tibial tuberosity transposition, trochlear groove deepening, and corrective osteotomies, we can appreciate the obvious philosophical differences between surgery and IRPM. This dichotomy harkens back to the carpenter-and-gardener metaphor. Whereas the carpenter seeks to achieve a specific outcome by following a predetermined plan, the gardener cultivates a nurturing environment that allows natural processes to foster recovery. Similarly, the gardener-style approach to PL would match mechanisms of dysfunction, pain, and mobility impairment with the mechanisms of healing that an IRPM modality stimulates. Often, multiple modalities have overlapping mechanisms; this gives us flexibility to introduce therapies that work best for this individual dog, cared for by this particular client, and is what this individual clinician deems needed in this instance. First let’s look at the tracking problem itself. In dogs with medial luxating patella, as mentioned, some tissues become too loose, while others become too tight. Utilizing myofascial palpation, a clinician may find hypertonicity and shortening of muscles on the medial aspect of the pelvic limb, most notably the vastus medialis and sartorius. If so, several treatment methods may help to reduce that tension, including medical acupuncture, massage, photomedicine, and stretching. We may also question why medial hypertonicity exists in the first place and subsequently proceed to assess the integrity of the coxofemoral joints. Dogs with ligamentous laxity and hypermobility of these joints may compensate for the weakness in their stance by overrecruiting muscles of the medial thigh. This, then, may cause chronic pulls on the patella toward the midline, accentuated by concomitant restriction in the fascial entities that course through that region. Thus, a luxating patella may be corrected by first addressing weakness in the hips and pelvis. For hip strengthening, one might begin by applying kinesiology tape to the gluteal muscles to build kinesthetic awareness of them as the dog walks. In addition, a therapist may repeatedly tap, massage, or electrically activate the gluteal muscles while the dog is standing, shifting the weight back and forth to further enhance proprioception. Soft tissue therapy (myofascial release, massage, and stretching) may be performed to restore length to the restricted myologic and fascial entities, including those mentioned above, along with the iliopsoas muscle complex. Hind limb problems can result in tension in the neck and shoulders. Here, Bindo receives dry needling along the caudal back and hips for secondary myofascial strain. Photo courtesy Dr. Adrianna M. Sage Final thoughts In summary, each dog’s rehab plan will take into account the type, severity, and location of pain, as well as inflammation edema, acute injury or chronic changes, range of motion indicating hyper- or hypo-mobility, neuromotor patterning, and comorbidities. Structurally, the veterinarian would assess posture and spinal mobility, relative tone and bulk of muscles in all four limbs, neurologic status, and myofascial strain patterns from nose to tail and topline to toe. We would ask how much exercise the dog gets and what is expected of them. We need to limit running, jumping, stair climbing, and activities that require rapid changes in direction. Swimming or underwater treadmill exercises may play a huge role in the dog’s recovery, and throughout it all, communication remains open between client and clinician so the capacities as well as the limitations of their own abilities are considered along with those of the dog. IRPM does not mean surgery is out of the question; it should just not be the first and only option clients hear. Narda G. Robinson, DO, DVM, MS, FAAMA, practices osteopathic medicine and veterinary medicine. Dr. Robinson taught science-based integrative medicine at the Colorado State University College of Veterinary Medicine and Biomedical Sciences for 20 years. In 2016, Robinson established her academy in Fort Collins, Colo., where she teaches medical acupuncture, integrative rehabilitation, medical massage, and other integrative medical approaches. Dr. Robinson is now offering programs in Sidney, British Columbia. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News. References Di Dona F, Della Valle G, Fatone G. Patellar luxation in dogs. Vet Med (Auckl). 2018;9:23-32https://doi.org/10.2147/VMRR.S142545. Dunlap AE, Kim SE, Lewis DD, Christopher SA, Pozzi A. Outcomes and complications following surgical correction of grade IV medial patellar luxation in dogs: 24 cases (2008-2014). J Am Vet Med Assoc. 2016 Jul 15;249(2):208-13. doi: 10.2460/javma.249.2.208. PMID: 27379597. Rossanese M, German AJ, Comerford E, et al. Complications following surgical correction of medial patellar luxation in small-to-medium size dogs. Vet Comp Orthop Traumatol. 2019;32(04):332-340. Ibid. Ibid. Harasen G. Patellar luxation: pathogenesis and surgical correction. Can Vet J. 2006 Oct;47(10):1037-9. PMID: 17078257; PMCID: PMC1571132. Ibid. Ibid. Ibid.
