Archive for June, 2009

You have probably heard of athletes rupturing their “ACL”  but didn’t really know what that meant.   The abbreviation ACL stands for “anterior cruciate ligament”.  This ligament is found inside the knee joint and helps to maintain its overall stability.   When this cruciate ligament is stretched or torn as a result of a sudden traumatic movement the  knee joint is no longer stable and begins to move in abnormal ways.   This abnormal movement results in pain, cartilage degeneration and eventually in arthritis.   Conventional medical advice for a cruciate ligament (ACL) rupture would be to have the knee repaired surgically.   There are several surgical techniques which are all quite effective in returning the knee joint to normal function, however, they are all quite expensive and have a 3 to 6 month re-cooperative period where the dog is significantly favoring the leg and placing additional stress on the opposite leg.   

In a large breed young animal cruciate ligament surgery may be the smartest thing to do but in an older animal the surgery may not be the best route to follow.    Consider first that neither anesthetic nor surgery is easy on an older animal.   Secondly, understand that the surgery will cause the animal to bare weight entirely on the opposite limb for a good 3 months.   This added stress can lead to  both arthritis and occassionaly a  cruciate ligament tear in the opposite hind leg.    The two most recommended cruciate surgeries are the “ lateral suture technique” and the “TPLO”.   Both are equally effective in the long run and both have inherent problems.     The suture technique surgery uses a heavy duty suture to stabilize the joint.   Although rare, this suture can slip, break or even get caught up on arthritic spurs already  present.    The TPLO is a more aggressive surgery where a portion of the tibial bone is purposely broken in order to change its alignment with the femur.   The TPLO knee surgery has more risk of bone infection and could even result in a non union fracture.   It is a significantly more expensive surgery  and produces no better long term outcome than the less aggressive less expensive suture technique.   The TPLO surgery may fail to produce the hoped for stability and is more likely to result in arthritis than the lateral suture technique.

For all of the above reasons, do not jump into surgery without first considering other options.   If you search the internet you may discover articles on “prolotherapy” as a method for rehabilitating damaged joints.   Prolotherapy has been used for over 30 years to repair hyper mobile, unstable joints in humans.   It however is just starting to take its rightful place in veterinary medicine, although it may still considered to be in the realm of alternative medicine.   Prolotherapy, proliferative, or sclerosing therapy are simply different names for the same thing.   Prolotherapy is a  way of tightening up loose unstable, hyper mobile joints  by injecting a “sclerosing” agent in and around the joint.    The sclerosing agent produces a thickening of the  joint capsule and of the external ligaments  of the joint.    This thickening of the ligaments act like scar tissue and eventually contract with time.    The thickening and contraction of the ligaments and joint capsule increase joint stability and relieves joint pain.     Prolotherapy commonly takes place in 5 sessions spaced approximately 3 weeks apart.    During each session the joint is shaved and disinfected with a surgical scrub.    Then multiple injections are carefully placed in the ligaments and joint capsule and even into the joint space.     Because of the number of injections most dogs will need to sedated but usually not anesthetized.    Although I tell caregivers not to expect any positive results until at least the third treatment I am occasionally  surprised to see improvement after just one treatment.   Although side effects from prolotherapy are rare, a joint infection is possible and consequently I surgically scrub the knee before each prolo session and give antibiotics to go home.    In very rare occasions it is possible for prolotherapy to injure a nerve passing by the knee however this has never happen to me and should not happen if care is taken to apply the sclerosing agents only to those areas of the knee where nerves are abscent.

In order to encourage more rapid joint thickening I often apply soft laser therapy to the knee with a non cutting therapeutic laser device that employs 5 lasers of various frequencies .   Soft lasers are therapeutic devices that should not be confused with surgical lasers.    The soft laser is painless, quick and has next to no adverse side effects.   Soft laser therapy supports the prolotherapy by further encouraging fibrosis  of the joint capsule and external , ligaments.   I also recommend oral doses of  “Orthoflex” and vitamin C be given at home throughout the prolotherapy process.    Other  modalities  I often recommend  be used in conjunction with prolotherapy are cold laser therapy and  pulse magnetic therapy.    The pulsed magnetic waves reduce pain and help the joint recuperate.   Cold laser therapy is used to speed up the scar formation.  Finally, to further support the prolotherapy, injections of  “Adequan” and “Legend”  can be given under the skin  to encourage cartilage  and overall joint rehabilitation.   

Prolotherapy for torn cruciate ligaments may not be successful if there is a torn meniscal cartilage in the joint.   It is also possible that in spite of multiple injections the thickening of the external ligaments may not be adequate to stabilize the joint and consequently the dog’s lameness remain.    That being said, when the choice is between joint surgery or prolotherapy, prolotherapy being safer, less invasive and less expensive makes more sense especially in the senior patient.

Prolotherapy can be performed on almost any joint of the body.  Personally I have  performed prolo on knee joints, elbow joints, hip joints,  the sacro illiacs joints and the lumbo sacral joints.

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