CCL tear and possible meniscal tear

[JuliPotter]

Dear Laurie,
I recently met Yona, a 5 year old MN Rottie who has had intermittent lameness on the left pelvic limb for the past 6-12 months. The owner reports that Yona's lameness got worse in July so she took him to her vet for an exam and rads. Yona was diagnosed with a CCL tear in the left stifle and was dispensed carprofen. Because Yona has not improved much since his last vet visit, the owner brought Yona to see the vet I work for... The vet did a lateral radiograph of the stifle and stifle effusion was noted along with periarticular osteophytes. The vet dispensed gabapentin instead of carprofen because Yona vomited while at the clinic and the vet said there was blood present in the vomitus. The vet referred Yona to me for an evaluation. Yona is currently taking a glucosamine supplement, Glycoflex, and CBD.
here are my findings -
Pictures of Yona - https://photos.app.goo.gl/2sGtxEB1FZvrWvMaA (I will email these to you as well)
October 4, 2022
BSC 5/9. Yona is lame on the left pelvic limb; he toe touches while walking and standing. I did notice that the paws of the forelimbs turn out slightly. (the owner said that as a puppy his front feet turned out). When Yona sits down, he lowers himself very slowly. Yona appears to have muscle atrophy over both eyes, with the right side seeming more atrophied than the left (though I don't appreciate this as much in the pictures). Yona has decreased muscle development in all four limbs. Muscle atrophy is worse in the left pelvic limb, even the left rear paw appears smaller than the right. Yona’s neck is tense but no obvious pain is noted with side glide of the C-spine. Noted decrease of flexion and extension (mild) of both the left and right carpus, decreased elbow flexion which is worse on the left, on the point of the elbow (caudal), there is hair loss and the skin is thickened and hyperpigmented. Noted decreased glenohumeral extension bilaterally and Yona is reactive with scapular glide on the right. No obvious reactivity noted along the thoracic or lumbar spine or at the L-S junction. Noted warmth at T-L junction. SIJ- the right ilium is more caudal and dorsal compared to the left and Yona is reactive with palpation of the right sacrotuberous ligament and the right piriformis. Noted decreased CP on both pelvic limbs. Quadriceps and sartorius are tight, Iliopsoas is tight, R>L, left stifle – medial buttress noted, Yona seems painful with attempt at cranial glide in mid-range, noted clicking with flexion and extension of the left stifle, resists hip extension, bilaterally, did not check pure coxofemoral extension since Yona was so tense when I attempted hip extension, Yona does not seem painful with palpation of pectineus or deep gluteal. The left medial malleolus does appear thickened to me but this may be because there is so much muscle atrophy present, and Yona does tense up with flexion and extension of the left tarsus.
My assessment is that Yona has a CCL tear of the left stifle which is chronic and I do believe he may have a meniscal tear as well. My concern is that he has remained toe-touching/painful for so long. It seems that dogs often improve with time, even though this is not ideal and the joint will develop OA, but Yona has a medial buttress, effusion, the lameness started over 6 months ago and he is still quite lame & painful. I am concerned that he has such little muscle development in general but in the thoracic limbs, this may be due to his conformation and decreased reach in the shoulders/straight shoulders, added to the fact that he is weight shifting forward to take weight off the rear end. The atrophy in the right pelvic limb may be due to SIJ dysfunction, possibly hip dysplasia/OA ....so I am wondering, can we see these persistent symptoms in a dog with a torn meniscus? and if so, is a Hero custom stifle brace a good treatment option? The owner does not want to do surgery. I started laser therapy, I did manual therapies, including for the SIJ, and have suggested avoiding jumping, running & slick surfaces, to do short walks, ice after activity, PROM, encourage AROM by tickling Yona's belly and toes, joint compressions of the stifle. I suggested a fatty acid supplement and may suggest Myos muscle support as well. My first goal is to try to make Yona comfortable. I am wondering if there are any other considerations for treatment with a meniscal tear.

Thank you so much, Laurie!
Juli

[lehughes]

Hi Juli,

Well, you could try a round of treatment (i.e. modalities to the joint, and you could try the distraction-rotation technique for meniscal tears). (Video Training 9 is the one regarding treatment of meniscal tears.)

However... this is a case that I would recommend surgery. At this point, the meniscal tear will inhibit functional improvements.

So, I would suggest progressing as follows:
1. Tell the owner that this seems to be a case that would do best with surgery.
2. However, you are willing to try a round of therapy (i.e no more than a month) to see if improvements can be made. (And find some objective measures - i.e. Thigh circumference, weight bearing on 2-scales)
3. Re-evaluate and revisit the surgery discussion.

My synopsis is, you could do everything possible, but if there is a meniscal tear in the joint, it won't get better! Sometimes surgery is the best rehab option.

Best of luck,

Laurie

[JuliPotter]

Laurie,
Thank you so much!
Juli

[JuliPotter]

Laurie, I hope you don't mind this question.....do you know of any therapeutic lasers that owners can purchase to use at home? I could have sworn that I read that a therapist or vet was recommending one for owners, but this was a while ago....well, I mentioned this to Yona's mom, just making conversation, and now she is asking me what product I recommend and where she can get one!
If you are familiar with such lasers for home use, I am curious what your thoughts are on this!
Thank you,
Juli

[David Lane]

I agree with Laurie that this is a surgical case - no other treatment will give you the same results.

Re: lasers - I just take the simple route and direct people to contact spectravet. They have a cheaper rig with limited options but are less expensive that are appropriate for owners.

[JuliPotter]

David, thank you so much!
Juli

[lehughes]

And on the laser front - yes there are other companies... but I'm also a Spectravet fan.
There are some 'human' portable ones - a professional would need to order it FOR the client. I've done this once.
I hear a lot of UK physios rent out / recommend Photizio as an option. I've looked into it. It's perhaps good enough for an owner to use... but I'd not have one as my clinic unit.

Laurie

[JuliPotter]

Thank you so much, Laurie!
Juli