Grace's Rehab

Thursday marked 6 weeks after Grace's ACL surgery. We had a post-op appointment to check healing - Dr. Muldoon pronounced her leg solid - then had a visit with a veterinary technician who has had specialized training in physical therapy for dogs.

Shawn Combs works at the VCA Tennessee Avenue Animal Hospital in Cincinnati. As well as being a Registered Veterinary Technician, she is a Certified Canine Rehabilitation Practitioner, having attended the canine rehab courses at the University of Tennessee after her graduation from the University of Cincinnati's Raymond Walter's Veterinary Technology Program.

I was very interested in this appointment, not only for Grace's sake, but to check out doggy PT. It is always easier to recommend a boarding kennel, dog trainer, or health care professional to my clients if I have been there myself with my pets.

Grace relaxes on the comfy mat
in Shawn's tiny office

Grace meets Shawn

First, Shawn took some measurements of Grace's leg, comparing it to her normal left leg.

thigh circumference

Checking the degree of flexion

and extension of the stifle

Next, warming up the joint and massage ...

... before beginning passive range of motion.


Bicycling. This retrains the nerves and muscles in a leg that hasn't been used much for a month and a half.


To strengthen the thigh, Shawn had Grace doing "Sit to Stands," that is, moving from a Sit to a Stand position and back. Having a well-trained dog is helpful here - Grace already knew the commands "Sit" and "Stand" from our obedience work, and was used to doing "puppy push-ups," moving from a Sit to a Down and back, so this step was a snap for her to understand.

Another exercise that accomplishes the same thing is "Limbo." Grace's eyes lit up when she saw this arrangement of PCV poles. It looks a little like an Agility jump, but the idea is for the dog to lower herself under the cross bar instead of jumping over.


Grace took this obstacle in her stride. Being coaxed with a liver treat had nothing to do with her eagerness to try a new trick.

"Everybody limbo!"

Cavalletti poles. A concept taken from the equine world, cavalletti are low rails that train a young horse to pick up its feet and gauge the distance between the poles, in preparation for jumping. In rehab, it helps with strength and coordination.

At the end of our hour-long session, Grace unwound with a cold pack on her knee.

I can see where rehab can be a useful tool in a dog's post-op recovery. My biggest problem is that Grace's physical therapy is aggravating the impinged nerve in my neck. Any time I work with her, my symptoms get worse. Gotta find a way to help us both heal ...

ACL Update

Sunday was Grace's tenth day post-op. I took out her stitches.


Her leg is looking pretty good, and she is about 50% weight-bearing. Now comes the tough part - not letting her do too much too soon. Hard for both of us to keep the activity level to a minimum.

Word of the Day: Sequela [Latin]

A pathological condition resulting from a previous injury or illness.

"Grace's ACL repair could break down as a sequela from too much activity during her recovery."

SOS from Grace

Hullo, Internet people? My name is Grace and I am a Rottweiler dog and I think you might have heard my Mama talking about me lately. Well, I need someone to help me. You see, my leg wasn't working right and my Mama took me to see that nice man that I like very much and he petted me and told me I was pretty and then he gave me some weird medicine that made me very sleepy and when I woked up, there was this big cut on my leg. Well, it hurt some of course, but I am a ROTTweiler which as you know is a big, strong, brave dog and I only cried a little bit and Mama gave me some medicine that made the hurt go away and I really think my leg is getting better already, but now I have a new problem.


You see, these little threads in my cut are making my leg very, very itchy, and you know, when something itches, you just HAVE to lick it and so I was licking it last night, and Mama said "Grace, no lick." Well, I am a Very Good Dog and I almost always do what Mama says, unless there is a good reason not to, and so I tried, I really, really tried, but then I just HAD to lick again. And then Mama got out That Awful Thing that she made me wear once before and she put it on me and it is STOOPID and I hate wearing it because I keep bumping into things and those damn cats are laughing at me behind Mama's back and ooooh, I am so sorry I said a bad word, but really it is not nice of those mean ol' cats to laugh at me.


And so I wrote a letter to my Auntie Lisa who loves me and only has that other dog as a temporary substitute because she misses me so much and I asked her to ask Mama to take the Awful Thing off, but she won't. So please, I know that a lot of you love dogs and you would never make them wear an Awful Thing and so won't you puh-LEEZE tell Mama to TAKE THIS THING OFF! I promises that I won't never lick my leg ever, ever again. Thank you very much.

ACL Injury and Repair, part 2

So, now that you know what causes an ACL rupture, what are we going to do about it? Small, lightweight dogs with partial tears might heal with cage rest and pain meds, but most dogs require surgery. And if something needs orthopedic surgery, then I am going to refer you to a specialist. I don't do bones!

Dozens of surgical techniques have been tried over the years, but these days, we are down to two basic procedures - lateral imbrication and the TPLO.

The older procedure, lateral imbrication, involves passing a heavy-gauge suture from the lateral fabella (the little bone behind the knee joint ) to the crest of the tibia and tightening it down. This takes the place of the ACL, keeping the joint stable until scar tissue forms.


In this X-ray of Grace's knee, the fabellae are the three little bones behind the knee. There are two larger ones behind the end of the femur, and a tiny one behind the top of the tibia. The tibial crest is the ridge of bone that comes to a point at the front of the shin bone. The line between the fabella and the tibial crest follows the same angle as the old cruciate ligament did.

This is the procedure Grace had done, and this is what it looks like afterwards:


TPLO, Tibial Plateau Leveling Osteotomy, is a newer, more high-tech procedure. In this surgery, the tibia is cut and a piece of the bone is rotated and reattached with a specialized metal plate, thus changing the angle of the joint. The theory behind this surgery is that the angle of the joint is too steep, and thus the forces on the knee are too great. Those who advocate TPLO feels that the stifle needs "leveling" to eliminate those forces.

Many veterinarians feel that a lateral imbrication is only appropriate for smaller dogs, and that a TPLO is the only choice for large breed dogs. I don't have a three-dimensional brain, which is why I don't do orthopedic work, so I trusted Dr. Shrader. This is what he explained to me.

Because you don't open up the joint capsule in a TPLO, like you do in a lateral imbrication, the dogs are back on their feet faster, in two weeks instead of 1 to 2 months. From an owner's point of view, as well as a surgeon's, this is a Good Thing. We all want our pets, our own as well as our patients, to be back to normal as soon as possible.

But, he continued, in both procedures, dogs must be leash walked only for 4 to 8 weeks, and then gradually returned to full use of the leg. After 6 months, he said, there is no difference in the use of the two legs. Both knees are at risk for arthritis, perhaps less so in the TPLO leg.

I chose the imbrication for several reasons. Number one, I wanted Dr. Shrader to operate on my dog, and he only does this procedure. A TPLO might get her on her feet faster, and would be my choice if she were a young, working dog, but given the fact that Grace is 8 1/2 years old and is slowing down, I don't need her to perform at a working level. I doubt we would ever do any more agility work, anyway. The TPLO surgery also has a higher failure rate - infection, problems with the plates and screws, and nonunion of the osteotomy site are a few of the potential negative outcomes. Finally, a TPLO would cost about $1000 more than an imbrication. With a 30% chance that her other ACL will give out, I need to save my pennies for the next procedure!

There are many opinions on these two surgeries. Please go to the two links above for one surgeon's input. If your dog needs ACL surgery, discuss it with your vet and get at least one other opinion before you decide. What's right for Grace and I might not be right for you. If you choose a TPLO, the surgeon will have had specialized training in this procedure. Many vets, generalists like me as well as surgical specialists, can do lateral imbrications, but find out what that vet's track record is - how many surgeries s/he has done, and the success rate - before you commit your pet to his/her care.

Post-op instructions: Strict leash walking for 6 weeks, "necessary" trips outside and then right back in, that's all. Do you know what a hassle this is for somebody who is used to letting her dogs out three or four times a day unsupervised, knowing they will stick close to home? Still, we will follow doctor's orders, especially when he called it "protecting my investment."

Dr. Shrader is letting me manage Grace's medical care post-op. Other than wanting her on three days of antibiotics after surgery, he has given me freedom to choose her medications.

For our post-op antibiotics, 1000mg cephalexin (2 capsules) twice daily for 3 days.


For pain control, an NSAID (Non-Steroidal Anti-Inflammatory Drug) - 50mg Deramaxx once daily


combined with an opioid (morphine-like) drug, Tramadol. The two drugs work differently, and are a good combination. For the first 3 days, I had her on 200mg (4 pills) twice daily, but have cut her dose in half as of today.


Both dogs have been on Glycoflex II, a joint supplement, for some time, but during recovery, I have doubled Grace's dose to 1 tablet twice daily.


And, I added injections of Adequan, twice weekly for 3 weeks, to help stimulate healing of her joint cavity.


Well, that ought to be enough about knees to last you for a while. I will continue to update you on Grace's progress. Thanks for caring about my girl!

ACL Injury and Repair, part 1

"Every cloud has a silver lining." "When life gives you lemons, make lemonade." If Grace had to have knee surgery, at least I can get a few blog posts out of it, no? This way, she and I can help educate others about life after an ACL.

First, some anatomy:

I don't know who created the knee, but it is the worst designed joint in the body. Instead of a ball and socket joint, like the hip or shoulder, the knee joint is simply one bone sitting on top of another, held together by several ligaments.

In this first drawing of the knee (stifle) joint, we have the bottom of the thigh bone (femur) sitting on top of the shin bone (tibia.) In between the bones are the menisci (singular meniscus) - cushions that act as shock absorbers of the knee. The kneecap (patella) is at the very top of the drawing. On either side of the stifle joint are the collateral ligaments, those on the sides of the knee. In the middle are the two cruciate ligaments.


Cruciate comes from the Latin crux, meaning cross. You can see the crossed ligaments forming an "X" in the middle of the joint. The ligament in the front is the Anterior Cruciate Ligament, which vets call the Cranial Cruciate Ligament. I'll use the abbreviation ACL for short, since most people are familiar with that term. It is the one most prone to injury or failure.

These cut-away drawings show the ACL, highlighted in pink, in action. The first drawing shows the knee in extension (straight)


while the second drawing shows the joint flexed. In this second drawing, you can see the tension in the ACL as the knee bends. It is this action which puts the ACL at risk for trauma or failure.


If you watch any sports at all, you have surely heard the phrase "blew out his knee," or "ruptured his ACL." Traumatic ACL rupture occurs when the leg is suddenly rotated while the knee is bent at a 20-50 degree angle. This might happen if the dog made a sudden right turn while bearing weight on the right rear leg. The internal stresses cause the ligament itself to rupture, or cause it to tear loose from its attachment to the bone.

Ruptured ACL

How does your veterinarian diagnose a ruptured ACL? Or, better yet, how do I diagnose an ACL in every other dog that comes through the door except mine?

History is very important. "He was running in the back yard and suddenly, I heard him cry out. He came back carrying a back leg, and he won't put it down at all." Most people guess "broken leg" with these symptoms, but my first guess is always a knee injury. ACL is the most common cause of acute rear leg lameness in dogs.

Breed, age, and body type are important clues in making the diagnosis. Large breed dogs, like Labradors and Rottweilers, are predisposed to ACL rupture, although I have seen it in small breed dogs like Beagles and even in one cat. There are two basic types of dogs who present with ACL: middle aged, overweight, sedentary "couch potatoes," and young, athletic, active dogs. While the exact mechanics vary between the two types, the end result is the same.

On physical exam, there is usually some degree of pain on manipulation of the stifle joint, laxity (looseness) in the joint, called a "drawer sign," and occasionally effusion (fluid) in the knee joint.

demonstrating drawer movement

Radiographs (X-rays) are usually negative for any abnormalities, but are often taken to rule out other injuries.

Grace's right rear leg

and her (normal) X-ray
Sorry, I couldn't flip the picture to keep the orientation the same.

So, how did I miss the diagnosis of ACL in Grace's case? Well, first, I told you I wasn't always rational when it comes to my own pets. Secondly, Grace's history didn't fit the typical ACL presentation. Yes, she is an older Rott, but she is neither overweight and sedentary nor young and athletic. Also, she didn't present as an acute, non-weightbearing lameness, but as a slowly progressive condition. Finally, I was unable to demonatrate any laxity (lack of drawer sign) whenever I palpated her knee joint.

Dr. Shrader explained to me that Grace most likely had a degenerative failure of her ACL, rather than an acute trauma, which fit her clinical signs and the slow progression of her lameness. Also, he showed me how she was painful on hyperextension of the joint, something which he said was classic for ACL. When I asked about the lack of a drawer sign, he told me, "I think we rely too much on drawer sign for diagnosis," and gently reminded me that "Every stifle lameness is ACL until proven otherwise," something I knew, but blanked out.

Next post: Two surgical options for ACL repair, and I why chose the one I did.

Gracie's Home!

Grace came home last night, but we were both too exhausted from stress and pain (her leg, my tooth) to do much more than crash and sleep. Today, we both feel better.

Because a lot of people that I worked with at the EVC now work at the CARE Center, Grace saw some of her old friends, and met some new ones, too. Dr. Daniel and animal nurse Gloria were both there when I picked her up, and nurse Aimee ran her anesthesia the day before. Everybody commented on how good and sweet she was, naturally.

Depsite her many fans, Grace was eager to go home. Here she is, pulling the assistant across the waiting room, trying to get to me. I didn't have time to compose a photo, just aimed and shot, as you can tell.


It is always harder, seeing your own pet post-operatively than a patient. Grace whimpered as she climbed up into the back seat to leave, and again when she got out of the car. Back at the office, we loved on her and gave her treats, then put her in a cage up front for the rest of the afternoon. She ended up with her face in a back corner, and I had to turn her around so she could see out.


I don't know if you can tell, but she was a little distressed Friday afternoon. Her face, as well as her body position, shows her level of anxiety, especially compared to the more relaxed photos from Thursday's post. She wouldn't take her pills in Pill Pockets, so I had to force them into her. She wouldn't even eat a Trader Joe's chicken jerky strip, until I broke it into tiny pieces and hand-fed them to her, one by one. She just wasn't my Gracie, and it was breaking my heart.

When we got home, Holly had to sniff her all over, especially her leg, till Grace actually growled a little, totally out of character for her.

Today, she is not crying, is more interested in food, and is pulling me as I walk her around the yard on a leash. She made the rounds of the bird feeders with me when I filled them this afternoon. When we came back in, I had her lay down in the living room, in front of a space heater (which she loves) while I went to my computer room, but she wouldn't stay. She got up and followed me back here, and is laying in the sunbeam, keeping me company. That's more like her!

This is a typical posture for a dog 24 hours post-op cruciate surgery:


Actually, in Grace's case, I think it is a little better than average. Most dogs don't put the foot down for several days, and she is actually touching her toes to the ground, although not bearing any weight as yet. That's good. We don't want her to stress that healing joint just yet. In fact, we have 6 weeks of strict rest - leash walk for potty trips and that's all - before we can start any kind of rehab.

Wanna see my new digital SLR camera?

Grace's right rear leg after ACL surgery

Looks a lot like a Rottweiler leg, doesn't it? I had planned on using my income tax refund for a new and better camera, but instead I put it into Grace's surgery. Oh well, there's always next year for a new camera.

Here's a photo of a trip to Scotland:

Grace's left front leg after radiation therapy

How many legs does this dog have, and when will I be done paying for them?

Grace Goes to the Vet

Grace Ellen

I know, I know - I can hear you all saying, "Grace lives with a vet, why would she need to see go some place to see one?" Well, as much as this pains me to say, I don't know everything, and I can't diagnose everything I see. [I know - you are all stunned by this confession, aren't you?] Plus, when it comes to my own pets, I am not always objective.

Grace, my beloved 8 1/2 year old Rottweiller has been lame for over two months now. It started about mid-November, as an occasional and subtle little gimpy step, so mild that I said to myself, "Did she just limp?" At first, I wasn't even sure what leg it was on, but by Thanksgiving, I had narrowed it down to her right rear leg.

At first, I did what any good pet owner would do: I ignored it. "Maybe it will go away," I rationalized. "After all, it isn't too bad, and she and Holly do some crazy things as they run around the back yard. Maybe she just pulled something. Maybe it will go away."

As the lameness became more pronounced, I could no longer take the head-in-the-sand approach. She was definitely painful in her right stifle (knee.) I started her on Rimadyl, an NSAID (Non-Steroidal Anti-Inflamatory Drug) like Advil for people, but I delayed X-raying her.

You see, in veterinary medicine there is a saying: "Osteosarcoma (bone cancer) is found AWAY from the elbow and AROUND the knee." And, in my dogs, my first thought is never "muscle sprain," but "Cancer." I didn't want a diagnosis of cancer before Christmas, especially just after the 20th anniversary of my father's death from lung cancer.

Finally, finally, finally I X-rayed her knee, hips, pelvis, and lower back. Other than some arthritis in her lower back, a normal finding for an older large breed dog, I couldn't find anything wrong. I changed her pain meds and waited. And waited. And waited.

She didn't get any better. Drastic measures were called for. I needed help.

Right before I left for my trip to Florida, I couldn't stand it any more. I called the Cincinnati Animal Referral and Emergency (CARE) Center for an appointment with Dr. Steven Schrader, veterinary surgeon and orthopedist extraordinaire. I felt like telling the receptionist, "My dog has been lame for 2 months. I need to make an appointment this week," but I didn't.

The CARE Center is a 24 hour emergency service, and they also have specialists for surgery, cardiology, oncology, neurology and internal medicine who see patients on a referral basis.

Charlie Harper mural in the entry hall at the CARE Center

Our appointment was today. We arrived a little before 10am to check in. "Have you been here before?" "Yes." "Are your phone numbers and address correct?" "Yes." "Who is your regular vet?" "I am." "oh."

the waiting room at the CARE Center. They have 10 exam rooms!
See the guy in the blue shirt? That's who we're waiting for.

Dr. Schrader is the vet I took Grace to last year, when she had severe pain from a mass on her rib cage which I was certain was cancer. He touched her and miraculously healed her. I was hoping for another miracle today, but he told me he could only do one miracle per century.

His exam revealed a cruciate ligament rupture. I was: a) Relieved it wasn't cancer. b) Embarrassed to have missed the diagnosis, since it is the most common cause of stifle lameness in a dog, and c) Stunned to realize he was talking about taking her to surgery. As in today.

Grace waits patiently for her vet appointment.

So, I signed the forms and gave them my credit card and left the hospital without my dog. As I type, it is 5:30pm and I still haven't heard from the hospital. To say I'm nervous would be an understatement. I have every confidence in Dr. S., but still ....

Isn't that a face to inspire trust? And Gracie loves him, too.

Every vet should sit in the client's chair at least once, to experience what it is like from the other side of the table. With Grace, I have been in that chair three times. I think that's enough.

Updates later, with a discussion of cruciate ligament rupture and photos.

Pray for Grace.

> Update: 9pm. I decided to keep my plans to go to pottery tonight, instead of sitting around, worrying. Dr. S. called while I was on my way there. Grace is doing fine, despite having some heart irregularity during surgery. She was still pretty stoned on hydromorphone, a pain killer, when he called. (And the dentist told me to take ibuprofen for my aching tooth. How come dogs get all the good drugs?) She'll spend the night in the CARE Center's ICU, and I will pick her up some time tomorrow.

Thanks for all the good thoughts you sent our way. I can feel the love!