344 Medical Management of Cruciate Ligament Rupture
the dog stifle and human knee is lacking. Clini-
cally, the signs of CR vary widely in dogs. Sub-
jectively, dogs that are affected bilaterally shift
their weight cranially more than dogs that are
unilaterally affected. While dogs with a large
amount of cranial tibial thrust during weight-
bearing are most often very lame, the presence
of dysfunction in dogs with CR does not cor-
relate highly with the amount of stifle instabil-
ity. Other than instability, the presence of a tear
or fold in the caudal horn of the meniscus, the
presence of severe synovitis, and the presence of
osteoarthritis may be other factors causing pain
and dysfunction. Dogs may also perceive acute-
on-chronic pain after surgery. In one report, 30%
of dogs had chronic pain after surgical treat-
ment of CR (Molsa ̈ et al. 2013).
Eliminating postoperative edema
Limb edema is a source of postoperative pain
and a potential factor promoting limb disuse
during the early postoperative period. Edema
typically subsides within 10 days; simple strate-
gies, such as cold therapy, minimize its severity
and accelerate its resolution. A decrease in the
invasiveness of surgery decreases the severity
of edema. Edema resorption is promoted by ele-
vation of the limb extremity, gentle tissue mas-
sage, passive range of motion and stretching,
cold therapy, and by the use of electrical stim-
ulation (Rexinget al. 2010; Drygaset al. 2011).
Maintaining or recovering stifle joint
motion
Stifle extension is more critical to correct limb
use than stifle flexion because the functional
range of motion of the stifle requires near full
extension but occurs far from full flexion. Stifle
joint extension may be negatively impacted by
capsular or periarticular fibrosis that developed
before surgery (Figure 42.1). Extension may be
further impacted by the suboptimal placement
of an extracapsular stabilization suture. Subjec-
tively, the most common surgical error leading
to a loss of stifle extension is the excessively
distal placement of the tibial tunnel. This prob-
lem may subside over time due to loss of stiff-
ness of the extracapsular stabilization suture
as a result of cyclic loading and the potential
Figure 42.1 This 4-year-old Great Dane had a cruciate
ligament rupture that was managed conservatively,
leading to joint fibrosis and a loss of stifle joint extension.
At the time of presentation, he was non weight-bearing
on his left pelvic limb and stifle extension was limited to
134 ◦, corresponding to a∼ 30 ◦loss of extension. Therapy
initially focused on preheating the joint and stretching the
joint manually.enlargement of bone tunnels. Surgical proce-
dures that alter the tibial plateau slope or dis-
place the tibial crest do not alter stifle joint
motion since they do not include a femoro-
tibial tether (Jandi & Schulman 2007). Stifle joint
motion should be measured with a goniome-
ter before surgery whenever possible, particu-
larly before extracapsular stabilization to differ-
entiate a chronic loss of joint motion from acute
loss of joint motion caused by the surgical pro-
cedure.Promoting controlled limb use
Limb use after CR stabilization surgery ranges
from good (mild weight-bearing lameness)
to poor (non weight-bearing lameness; Fig-
ure 42.2). Factors that are likely to lead to a
decrease in limb use include chronicity of the
problem including osteoarthritis, limb weak-
ness and quadriceps inhibition, neuropatho-
logical changes, surgical technique (residual
instability, medial meniscal injuries), and sub-
optimal pain management (peripheral sensiti-
zation, allodynia). Rehabilitation strategies to
facilitate limb use include pain management,
client education regarding controlled walking,
sling use (proximal stability to promote dis-
tal mobility), and active exercises to promote
weight shifting.