Nonsurgical Perspectives on CCL Disease

Author(s): "Andrea L. Looney, DVM, DACVAA, DACVSMR"
Published: Veterinary Practice News, October 2018

This third installment in a four-part series explores a wide array of nonsurgical treatment strategies for managing cranial cruciate ligament (CCL) injuries in dogs—particularly valuable when surgery isn't feasible due to cost, comorbidities, or caregiver limitations.

1. Intra-Articular (IA) Injections

• Platelet-Rich Plasma (PRP): Preferred for early-stage or uncertain CCL disease. Shown to reduce inflammation, stimulate healing, and improve mobility.

• Mesenchymal Stem Cells (MSC): May reduce inflammation and improve quality of life but are costlier and less supported by evidence than PRP.

• Hyaluronic Acid (HA): Used for joints with meniscal damage or bone-on-bone contact. Acts as an anti-inflammatory and joint lubricant.

• Steroids: Effective for acute inflammation and end-stage osteoarthritis, with immediate effects but long-term caution advised.

• Autologous Conditioned Serum (ACS/ACP): Promising in theory, but limited evidence of clinical benefit in canine OA.

2. Stabilization & Bracing

• Custom and semi-custom orthoses (e.g., Hero, OrthoPets, A-traC) help stabilize the stifle joint, enhance proprioception, and reduce mechanical stress.

• Success depends on proper fitting, ongoing monitoring for pressure sores, and owner commitment.

• Prolotherapy: Inflammatory injections (e.g., dextrose) to stimulate ligament healing; evidence is stronger in humans than in veterinary applications.

3. Exercise Restriction & Gradual Rehabilitation

• Strict activity restriction (no stairs, running, or jumping) is essential for 6–12 months, especially in large or active breeds.

• Gradual reintroduction of activity, along with support devices (e.g., Help ‘Em Up harnesses), can assist recovery.

4. Physical Rehabilitation

• Includes passive range of motion, massage, balance training, uphill walking, underwater treadmill, and neuromuscular electrical stimulation (NMES).

• Tailored progression supports healing, strengthens muscles, and improves mobility.

5. Photobiomodulation (Laser Therapy)

• Reduces pain and inflammation, and promotes tissue repair.

• Higher energy Class IV lasers are preferred for deeper penetration and chronic CCL conditions.

• Can complement PRP therapy and target specific joint compartments.

6. Weight Management & Nutrition

• Overweight dogs are significantly more prone to CCL injury.

• A high-protein, low-carb diet with added vegetables and lean proteins aids muscle repair and weight loss.

7. Anti-Inflammatory Strategies

• NSAIDs are commonly used unless contraindicated by other therapies (like PRP or prolotherapy).

• Alternatives include topical NSAIDs, cold therapy, polysulfated glycosaminoglycans, and natural remedies.

8. Sedation and Pain Management

• Sedatives (e.g., trazodone, acepromazine) help manage behavior during recovery.

• Analgesics like gabapentin and codeine may be used; tramadol is not recommended due to ineffectiveness in musculoskeletal pain.

Conclusion:
Nonsurgical management of CCL injuries, while more prolonged and labor-intensive than surgery, offers a viable and evolving alternative. With the right combination of regenerative therapies, stabilization, rehab, and pain management, successful outcomes are increasingly attainable for dogs unable to undergo surgical repair.