A case example of physical rehabilitation in a dog after stifle surgery
Bella, a 1-year-old spayed female Labrador retriever, was presented for rehabilitation therapy after bilateral anterior cruciate ligament rupture and subsequent extracapsular repair of both stifles. Initially, Bella's left rear limb was lame but the lameness shifted to the right rear limb the next week. Radiographs showed inflammation but no overt degenerative joint disease. Surgery had been performed three weeks before presentation, which was four weeks after the initial lameness was detected. Recovery was slightly complicated by an incisional infection on the left side, but the incision had healed by the time of presentation. Bella was receiving a glucosamine supplement as well as fish oil.
Initial findings included a body condition score of 3/5 (overweight), a bilaterally shortened stride length in both rear limbs with slight internal rotation through the contact phase, and a poor sitting posture with both rear limbs held to the side and thoracolumbar kyphosis. Range of motion measurements revealed marked restriction in hock flexion (L 66 degrees, R 72 degrees) and hip extension (135 degrees bilaterally) and moderate restriction in stifle flexion ( L 50 degrees, R 46 degrees). Extension in the stifles was slightly reduced (by less than 5 degrees). Bilateral medial buttress with joint capsule thickening and effusion was present, and the left stifle had excessive scar tissue at the incision. No statistically significant difference was noted in muscle circumference between the left and right sides.
The initial rehabilitation program included daily passive range of motion exercises, daily therapeutic exercises, and underwater treadmill therapy two or three times weekly. Laser therapy to reduce scar tissue in the left stifle was declined. The goal of therapy was to return Bella to her previously active lifestyle. Improvement in range of motion would be used as a measurable indication of improvement, and posture and gait analysis would be subjective indicators of return to function.Bella's treadmill program was initiated immediately. She was placed in warm water (92 F [33.3 C]) to a depth reaching her shoulder (below her greater trochanter and above her stifle). She walked for four minutes at a speed of 1 mph, which resulted in a brisk walking pace. She took even steps with both rear limbs, showing a correct stride length with no internal rotation. She showed typical exaggeration of hindlimb flexion. The session ended at the point of fatigue, indicated by her riding back on the treadmill (not keeping up with the speed). A five-minute massage was performed after the session, and Bella was blow-dried to prevent skin infection. During subsequent sessions, the exercise time was increased by 30 seconds to one minute based on her level of fatigue.
One month after therapy was initiated, Bella showed some improvement in range of motion (L hock flexion relatively unchanged at 65 degrees, R markedly improved at 55 degrees, L stifle slightly improved at 46 degrees, R improved at 40 degrees, and hips improved to 155 degrees bilaterally in extension). Bella's gait had become somewhat uneven, with a shorter stride and continued internal rotation on the left side but a larger more fluid stride on the right. Her left rear limb circumference was now 1.25 cm smaller than her right. Her posture was unchanged. Her therapy protocol was revised to improve symmetry and range of motion.
The underwater treadmill sessions were changed to incorporate the use of a balloon encircled above her left hock to further exaggerate flexion. The duration of exercise continued to increase based on her tolerance and averaged one or two additional minutes each session. Heat therapy before passive range of motion exercise on the left side was also recommended. Exercises were revised to address the new issues. One month later, Bella was again walking evenly, with a fluid long stride bilaterally. She was finally able to sit squarely, and her hock and stifle flexion had improved dramatically (L hock 50 degrees, R 46 degrees, both stifles 38 degrees— all normal or within 5 degrees of normal range). She was released from therapy eight weeks after her initial presentation.
Christine Jurek, DVM