Last week I evaluated another dog with persistent disuse & pain after CCL surgery ( for torn ACL / CCL).
Here is a copy of the synopsis I sent via email to the owner and to the vets. I had already made a phone call and left a message with one of the treating vets.
As promised, here is a bullet point email synopsis of our visit today. I am also sending a copy to Drs. Txxx, Exxx, and Wxxx since they have all been treating Dxxx. As I texted to you, I did contact Dr. Txxx after our visit, and I left a vm for her, trying to detail what I thought was going on with Dxxx. She and I subsequently texted a bit and she noted that she gave Dr. Exxx a heads-up since he is the one who did the surgery and since you may be contacting them tomorrow.
Dxxx is able to walk on sx limb and often chooses not to do so. He is 2-4/4 lame; 2 at a walk and 4 when faster. He is quite atrophied in L thigh, especially lateral. He is 7/9 PBS with substantial fat pads over both hips, adding to the deformed appearance of L hind. Fluid sac exists at L lateral stifle and you said the vets were aware of it and it was deemed a fluid collection related to suture. Mild to moderate effusion in L stifle, and I worked with owner so that she could feel it and become accustomed, able to tell in the future if/when it subsides. Dxxx has not consistently been receiving pain meds recently.
At this time out from surgery I would expect Dylan to be consistently using L hind and atrophy to be (mostly) resolved, no effusion.
1) Begin dosing analgesic this evening. You may use Metacam as previously directed and so long as his liver values are fine. You may use Tramadol as scripted on the bottle. We discussed the mechanisms of both drugs and the potential benefits/drawbacks. If his lameness is not resolved using these analgesics and/or possibly using the Gabapentin that you also mentioned he has been scripted, then you are to contact the vets no later than 2 days from the time of pain med dosing to discuss the possible use of antibiotics and let them know of the continued disuse on top of medication dosing. I have seen many cases like this that have persisted in lameness and had mild effusion (or no effusion) in which existed a low-grade, latent, painful infection. In these cases, depending on the antibiotic the vet chose to utilize, the lameness was mostly or fully resolved within two days, usually at the end of one day. Given Dylan’s dynamics (licking busybody), it is highly possible that this is what is occurring. The vets in other cases I’ve worked have chosen to dose the meds and not tap the stifle joint because the meds are relatively easy and the joint is then not disrupted nor the chance of new infection introduced. I touched on these ideas with Dr. Txxx, and I do not know what she passed on to Dr. Exxx, however they will discuss it further and will likely want to have a look at him if they have not seen him in a while. Please do not hesitate to call them sooner than in two days, and I’m sure they will be glad to talk with you or see you.
2) I recommended you follow this link: http://rehabilitationandconditioningforanimals.wordpress.com/category/homework-suggestions-for-functional-rehab/ to my “Homework for After Knee Surgery” and read it thoroughly. Begin working Dxxx at week 1 two days after most of the lameness has improved. Again, I expect the disuse to resolve with either pain meds or antibiotics or both, and in my experience it will resolve within two days of the medication that hits the problem.
3) Follow this link: http://rehabilitationandconditioningforanimals.wordpress.com/category/qa/ to Q&A about limping and knee pain after surgery.
4) Follow this link: http://rehabilitationandconditioningforanimals.wordpress.com/2011/07/30/water-treadmill-is-definitely-not-necessary-for-rehabilitation/ to more on joint pain, water treadmill, and rehab work.
5) Slowly reduce treats and a small amount of pm feeding. Measure the food he receives currently so that you are able to control the amount you reduce. Losing the extra fat will help with his function and protect his joints. Lots of research exists regarding this concept.
6) Begin giving ~200 mg EPA and ~100 DHA in fish oil daily. This amount may be doubled. You may use the brand you have or some from (the clinic).
7) Please keep me posted regarding his progress with the different meds. We will recheck in one week. In the future I intend to discuss massage. I believe acupuncture and laser therapy could help him, at least for the next 6-8 wks, as he resolves these issues. I expect him to be able to follow the homework protocol as written for the first 4 weeks after pain management and then we will discuss the program for weeks 5-8. After that, it is up to you, should he be improved and doing well, as to whether or not you would like further, more dynamic, homework.
AND, here is the owner’s follow-up report I received via email just a bit ago:
Hi Deborah, I was about to send you a quick text, when I saw this email (one I, Deborah, wrote asking how Dxxx was doing). Yes, Dxxx started antibiotics on Friday, and wow, what a difference. I saw almost immediately the change. Yesterday, almost all his walking was done with his leg down. I can really tell a difference. Thank you so much for getting us on the right path. I look forward to seeing you Tuesday.
He continued to improve and over about 3 months time he was equally muscular in both hind and had lost the extra fat he was carrying.
I have very many stories like this one, and I just now had time to share this one. 🙂
Hope it helps-