Possible Torn ACL (Cranial Cruciate Ligament)-How Should We Proceed?
I’ve enjoyed following the stories you post on FB about the dogs you heal, and who’d’ve thunk I might one day need your services?
My dog, K, has been gimpy for about a month or so (back right leg)… took her to our vet a couple of weeks ago. By poking and prodding, they figured it’s her knee. Gave us some anti-inflammatories and said to keep her from running, going up stairs, etc. It showed improvement during the first week, but then we let her back on the stairs and it’s back to the same.
My former vet friend, P, looked at it a couple of days ago… She strongly suspected an ACL tear.
I poked around a bit on your site, and it looks like there may be a nonsurgical route for ACL injuries…. I thought I’d ping you and ask you a few questions:
– What would our next step be? (we haven’t had x-rays or the “drawer-test” that Pam described to me)
– If we wanted to do any rehab through you, how would that work and what would the fees be?
K seems very happy and it doesn’t really slow her down too much (unfortunately! She wants to continue being the family dog that she is, around us all the time). Yesterday, we decided to confine her (like crate rest), but the problem is, the gimpiness seems worse after she’s been lying down for a while, then it seems to warm up and work itself out once she walks around a bit. So by keeping her confined, she’s lying on it a lot more and not moving as much, so it actually seems worse. (making me wonder if the confinement is the right thing to do…)
My Answer Today:
Goody…I happen to be home and able to give you a better answer via the pc keyboard!
The best option, imho, is to have me come out and do a consult regarding how you should proceed. It usually takes an hour for something like this. I prefer to see animals for the first visit in the home environment so I may discuss potential pitfalls and see home items we may use for drills, among other reasons. I am also able to do phone consults at $1/minute, but I prefer to see the pet in person…
The second best option is for you to go onto my rehab site and look under notes for the homework for post cruciate ligament rupture rehab.
I also have a video posted on YouTube and my WordPress site regarding a massage technique that is beneficial. The Pittie featured in the video is 3 years out from a cruciate ligament tear and never had surgery. He is doing great because the owner did the homework as I recommended. The YouTube link is on my WordPress and is under RehabDeb if you search it.
I do not think I would ever have surgery on one of my own dogs for this issue again. My little Grace had two TPLO’s, the major surgery where the bone is cut and replaced at a different angle, and both didn’t work out. One wouldn’t have worked out because she had a congenital joint disorder on that knee and the surgery wasn’t ever going to be solid, and on the other knee she ended up getting a raging infection at the time of surgery that eventually ate up the whole joint. The Grace had a poor immune system, and she was open too long on the table, due to unforeseen circumstances, among other things.
She was bone on bone in both knees for the last 3 years of her life, yet she was definitely full of life! She ended up tearing all three ligaments in the second knee, so far as I/we can tell, and it was muscle support of the joint that enabled her to function as well as she did. None of the available braces were of a good enough design for her, and I’m not a fan of what is currently available for most dogs, especially not without working on my walking and exercise drill protocol first.
I deal with many dogs whose owners don’t want surgery for a variety of reasons, and the feedback I receive is that they have done great without surgery.
Of course, I also do rehab with many pets that have had surgery also, from both boarded surgeons and regular vets, using all types of modifications.
I’d be glad to discuss the differences.
We don’t do surgery on every human athlete, much less every human, yet most of the dogs are immediately referred to surgery as if there isn’t another answer the vet knows to suggest. This is because the vets are trained to react in that manner, and they usually don’t have any foundation in muscle-building and joint support protocol. Most of the reasons I’ve heard given in favor of surgery aren’t necessarily scientifically correct, according to available research and anecdotal evidence. I’m trying to make my functional rehab protocol using principles of exercise physiology more readily available.
My background in sport science definitely gives me a huge edge in developing protocol for recovery, and it is just taking slow time, getting the word out and getting people to think more wholly about the situation, and to see/know therapies that exist in other areas of physical science and apply them here. The angle of a dog’s knee, or any quad-ped knee, is definitely different than that of a human/bi-ped, however many principles of physiology and of the relationship between soft and hard body tissue apply and are useful to improve function and quality of life.
(10-17-13 and now you may purchase the guide book for rehab of this condition at http://wp.me/p1wSDA-cU )
More Than Half of All ACL Reconstructions Could Be Avoided, Five-Year Follow-Up Study Shows
(From RehabDeb: This report is from human medical research, however animal studies are currently being conducted at Colorado State University. When I began animal rehab in 2005, I developed some protocol for people to use to benefit their animals if they did not want surgery for their pet, even though I was working at the time in a surgery specialty hospital. When I began independent practice in 2007, I took years of accumulated research, experience, and knowledge and created some simple functional exercise and drill protocol that has benefited hundreds of my canine patients whose people opted to not pursue surgery. That protocol and some other papers citing surgery text recommendations may be found elsewhere on this site-see the index to the right. In every case where my protocol has been followed (and there are no extenuating circumstances), the pets have stabilized the joint with muscle and scar tissue, and they have functioned very well. This work is all done in the home environment with no dependence on specialized equipment…no need when we are drawing from centuries of known exercise physiology and dynamic principles of body function. Blessings-)
Jan. 30, 2013 — In the summer of 2010, researchers from Lund University in Sweden reported that 60 per cent of all anterior cruciate ligament (ACL) reconstructions could be avoided in favour of rehabilitation. The results made waves around the world, and were met with concerns that the results would not hold up in the long term. Now the researchers have published a follow-up study that confirms the results from 2010 and also show that the risk of osteoarthritis and meniscal surgery is no higher for those treated with physiotherapy alone.
“We have continued with our study and for the first time are able to present a five-year follow-up on the need for and results of ACL surgery as compared with physiotherapy. The findings have been published in the British Medical Journal and are basically unchanged from 2010. This will no doubt surprise many people, as we have not seen any difference in the incidence of osteoarthritis,” says Richard Frobell, one of the researchers behind the study, who is an associate professor at Lund University and a clinician at the orthopaedic department, Helsingborg Hospital.
Richard Frobell explains that the research group’s results from 2010, which were published in the New England Journal of Medicine, caused a stir and questions were raised as to whether it was possible to say that an operation would not be needed in the long term.
Half of the patients who were randomly assigned not to undergo reconstructive surgery have had an operation in the five years since, after experiencing symptoms of instability.
“In this study, there was no increased risk of osteoarthritis or meniscal surgery if the ACL injury was treated with physiotherapy alone compared with if it was treated with surgery. Neither was there any difference in patients’ experiences of function, activity level, quality of life, pain, symptoms or general health,” says Richard Frobell.
“The new report shows that there was no difference in any outcome between those who were operated on straight away, those who were operated on later and those who did not have an operation at all. The message to the medical experts who are treating young, active patients with ACL injuries is that it may be better to start by considering rehabilitation rather than operating straight away.”
In Sweden, over 5 000 people every year suffer an anterior cruciate ligament injury — mainly young people involved in sport. There are different schools of treatment and Sweden stands out with treatment that is in line with the results of the study.
“On an international front, almost all of those with ACL injuries are operated on. In Sweden, just over half are operated on, but in southern Sweden we have been working for many years to use advanced rehabilitation training as the first method of treatment. Our research so far has confirmed that we are right in not choosing to operate on these injuries immediately. Longer-term follow-up is important, however, if we are to look more closely at the development of osteoarthritis in particular,” says Richard Frobell.
The research group, whose study is called KANON, Knee ACL NON-operative versus operative treatment, is now moving on to the next stage. This year, the third part of the study will begin, following up the patients ten years after anterior cruciate ligament injury.
Richard Frobell has also entered into a collaboration with researchers at the School of Economics and Management at Lund University to evaluate the health economics aspects of different treatment methods for ACL injury.
- R. B. Frobell, H. P. Roos, E. M. Roos, F. W. Roemer, J. Ranstam, L. S. Lohmander. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ, 2013; 346 (jan24 1): f232 DOI:10.1136/bmj.f232
- Richard B. Frobell, Ewa M. Roos, Harald P. Roos, Jonas Ranstam, L. Stefan Lohmander. A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears.New England Journal of Medicine, 2010; 363 (4): 331 DOI:10.1056/NEJMoa0907797
Questions About Hip Surgery
From the client:
You are so awesome!!! We took him to the vet yesterday and he gave me Rimadyl and Tramadol to help with pain and inflammation. I haven’t had him in for x-rays yet, would that be helpful for you? The vet said he didn’t see any signs of being hit by a car recently that would tell him that there was something broken. I was going to have him fixed this weekend, but I can wait if you think it would be best to see you first. You are worth every penny + some and I will be prepared to pay you for the time you spend with him. ;0) He is a shepherd mix about 14 months old. Just a baby with a sweet, sweet heart and a crappy start. Let me know if you want x-rays and if I should wait on having his boys removed and I can be available anytime Wednesday on next week.
I’ve been thinking about it, and I think it would be a good idea to get the manly-man surgery out of the way first.
When he gets pain meds for that, you may be able to see a difference in his demeanor or comfort, regarding his hips/legs, so take note of that.
Yes, and it may be hard to tell ;))
I can tell a lot without xrays, and often they get in the way in part of our brains regarding a better clinical evaluation. On the other hand, since he will be sedated, it will be a great time for x-rays, so go ahead if your vet is on board (which I’m pretty sure he will be!)
If he gets surgerized this weekend, I could see him next Thurs or Fri or when ever your schedule allows after that…
What do you think?
After our first evaluation, my bullet point recommendations were to
1) restrict and crate when not at home for the next 2 weeks.
2) Begin exercise protocol noted on my FHO homework sheet, beginning with week 2, 2-4×10 min walks daily, very slowly (wedding march).
3) Use medications as per label, giving the Tramadol 30 minutes to 2 hrs. prior to walking if possible. Regarding your dosing question and the variability noted on the label, give the larger dose in the morning if you will be walking him in the morning, otherwise just give the smaller dose. Give the larger dose when you get home in the afternoon/evening, in prep for 1-2 pm walks. Give 2 hrs. rest period in-between walks (as per homework sheet).
4) Feed grain-free kibble (no barley or oats or rice, either, right now), Omega 3 in fish oil capsules as discussed, and joint formula that contains at least two of the following: glucosamine, chondroitin, msm.
(after having some problems with Clark, a rescue, and other dogs adjusting)
We still have our friend. We made some adjustments and he seems to have settled a little bit. He has the sunroom to himself at night and during the day…we call it his puppy apartment. ;0) Everyone seems happy.
We took him off the Rymadal (SP?) because he was getting sick. And I’ve scaled back on the pain meds and give them when he is looking a little stiff. We are trying REALLY hard to stick to the directions, but I’m afraid it’s a modified version. He is still during the day and at night and we have shortened his time outside with the girls and I’ve been good at at least one walk a day…sometimes I get lucky and can get two. We will get it fine tuned…it’s just going to take a little time.
The vet is REALLY, REALLY pushing the surgery…I’m not doing Clark long term harm by not opting for surgery…right? You would think it by talking to him.
Anywho, thanks for checking in and the great direction. You idea to crate him at night helped everyone out!! ;0)
I will keep you posted on progress…just might be a little longer than 4 weeks.
Have a wonderful week!
Ok, so, I’m going to tie in our texts here and I think we should have a recheck to keep you guys on task…so that you see the improvements, and Clark improves, and others may see and reevaluate their insistance on surgery.
In Clark’s case, I don’t hear that anyone is concerned about gross malformation of the pelvis or a femur that is deformed beyond function, so there is no clinical reason to not employ muscle-building & joint strengthening techniques to appreciate improvement. The reports you have given me, verbal from the vet and the view of the x-rays, don’t indicate “horrible hips” and don’t indicate hips beyond the level at which others have improved without surgery. Clark is young. Perhaps your intervention staves off the need for surgery for the remainder of his life or perhaps it serves him well until he is older and then you may re-evaluate.
Usually in a case like this pain control plus the right type of exercise slowly improves the body and therefore the situation.
Some dogs improve, some don’t. The ones that don’t usually have owners who don’t do much of the protocol. So, if they keep doing the same thing as before, they get the same result, yes?
I don’t think you are in that catagory.
You guys represent a lot of families I see in my practice, in that you have two working adults, small child(ren), other dogs, etc…and several variations of this norm exist, of course. This norm is perfect for my home-based protocol because it only causes home-based disruption, in that you only have to sacrifice a little time, and my recommendations are based on 30+ years of my understanding of program design for improved function. This combo brings the biggest benefit, greater results, when all factors are weighed. And there is always the option to pay me to come do the exercise and drill work.
I know you get that
And of course my perspective is a little more broad, because I have seen a lot of what happens to animals in a wide variety of circumstances.
The most predominant point I make to clients is that the protocol does not get easier if the animal has surgery; in fact, it becomes an absolute necessity in order for the healing to occur and for the desired outcome from surgery. Without surgery, using my protocol, there is more room for letting something slip with less immediate ramifications, the main two of which post-surgically would be great damage to the surgery and money down the drain, since re-dos aren’t free (in most cases).
More than that is the additional stress and pain for the animal.
I am writing more here than need be to address you guys directly because I plan to share some of this discourse on my blog and giving more info helps a wider range of readers.
You said you stopped the Rimadyl because it was causing gastro distress…GOOD! And I presume from something you said in your texts that you let the vet know. You were not using the Tramadol as consistently, and I recommended you return to dosing as per the label for adequate pain control and especially since it’s all the pharmaceutical pain control you are using. Don’t forget the fish oil, grain-free food, and the glucosamine/chondroitin/msm…and I think you’re doing all that.
And you wondered if you were doing some sort of long-term harm by not having the hip surgery since the vet and staff seem so insistent on Clark having surgery. I covered this answer in part above. Additionally I will say that the exercise physiology and functional rehabilitation protocol I bring to veterinary rehab are not necessarily new to vet med, since race horses have been using protocol similar to that derived from human sport science for decades. These are, however, new concepts in small animal medicine, it seems. I came into vet rehab after 25 years experience in human sport science and nutrition protocol covering the gamut. These principles were novel where I began rehab practice, and I find the programs I have been designing for humans, based on much research performed by people living long before I came around, also are the most beneficial programs and protocol for animals for pre-hab, re-hab, and instead-of-surgery in many cases. No, you can’t just copy a program from Muscle and Fitness magazine…but you can pay attention and learn what actions produce what results. That will take time. The paying attention and learning…
There are some cases that really may need hip surgery, and when the clients have contacted me for pre or non-surgical intervention, at the very least we may say we are doing pre-hab. In the case of luxating hips, even though keeping the dog in a tight sling for weeks will/should work, as per science and experience, it seems almost impossible for most people to maintain the restrictions necessary for the sling to do its work. Disruption too soon=ligament laxity, again, and the ball of the femur keeps popping out. At any rate, it stands to reason that a body realising better function prior to surgery will improve easier post-surgically. That is also proved in research. Dynamic exercise improves every body system, from strengthening bones to improving the health of soft tissue.
I know for a fact, from years of study, evaluation, and observation, that cross-training rehab specialists in sport physiology and program design for dynamic function would elevate overall rehabilitation outcomes across the board. This has actually been an extreme discussion in Europe for the past yea-many years, that of the need for physiotherapists to have a deep(er) foundation in sports physiology and program design. I haven’t seen it hit here as forcefully yet (and we’re talking human medicine, which is paving the way in this arena). Europe is quite a bit more progressive regarding body wellness treatment and sport program design and a variety of similar topics.
Simply put, these exercises will not change noted gross malformations of the femur in an animal with hip problems, however, to note, any gravity-based exercise, weight-bearing exercise, will improve bone density, so changes along those lines will accrue. These exercises, performed as per a program designed for Clark, should improve tendon, ligament, and muscle strength, muscle size, and neuro-muscular signaling, simply put.
Other beneficial things will happen as well, as always do with exercise of the right type for a particular entity. The changes I noted should improve his overall function. To my knowledge, the surgical protocol is to not operate on hips based solely on x-rays and is to operate based on severity of clinical signs. That is what the surgeons say, and that is what the literature says. Vet surgeons in other parts of the U.S. will not operate on dog hips without having the clients do 4-6 weeks of pre-hab first, with the intent of gaining owner compliance and improving the dog’s health, most especially in cases of obesity.
So, the catch here is to have enough of the right variety(ies) of pain control on board while the dog is performing the best exercises for his/her situation and thereby learning to use the affected limb more freely again. With that increased use come the improvements I mentioned. With the improvements comes the need for less medicine, since increased muscle mass and supportive tissue strength will better support the joint.
That’s all I have time for right now, and I think this will help you guys.
Torn CCL/ACL on 10 yr. Old Lab, Been Torn a Year…
Hi Deborah – I’m so glad I found your blog/website after researching for hours. I am at a total loss of what to do for my beloved yellow lab, Sam. Sam is 10 years old, weighs 98 pounds (vet said he had a large girth) and that his weight was fine. A year ago this vet said he had a pulled or torn ligament in his left leg. She said he could have surgery even though he was old, or prescribe adequan (very expensive) or keep him inactive. There was no guarantee of either treatment. I kept Sam inactive for quite a few months, with limited leash walks. I thought he was getting better but he’s not. There have been a few times; he took off running across our yard, which I know was bad. But I’m more careful now about opening the door and him on the leash. I took Sam for a 2nd opinion yesterday (1 year later), this vet said he had a torn cruciate ligament and needed surgery. He gave no medication for pain or recommendation of using anti-inflammatories. Neither vet recommended Xrays or other tests. They just did the manually testing of his leg. He is slow to get up, limps for a minute but then walks on that leg, but does not put full pressure on it. He doesn’t limp when he’s walking. It’s mostly after he’s been lying down, he struggles to get up, limps for a minute or two, then he seems fine. I limit his walking to about 5 minutes 4 times a day. He never seems like he’s in pain. He’s always wagging his tail even when he’s lying down. The only thing I’ve really noticed is at night while we are watching TV, he normally sleeps; now he seems to stay awake and look around, which maybe that means he’s in pain, I just don’t know. I really don’t want to do surgery on Sam, not at his age. I’ve read quite a bit on your site, and it looks like there may be a nonsurgical route for ACL injuries…. I thought you might allow me to ask you a few questions: Deborah, I live in Foley Alabama, is there anybody like you my area that you know of? Anybody you can recommend? Can you give me any kind of advice of what I should be doing for Sam? Should I let the Vet give Sam Adequan? I will do it if you think it will help. When is surgery really necessary and should it be done on a 10 year old lab? I don’t know who else to turn to, please help. Thanks Lisa from Alabama
Here is the first answer I sent you via Facebook-
Here is my FB rehab page, and you may already be a fan, since we have at least one friend in common, but there is no easy way for me to search and sort who follows this page
I will get to answer your post on my website as soon as I can. Otherwise, I do know the answers to all of your questions are on one or both of my sites…it just takes a lot of reading ! So while you wait for me to be able to answer, check out the homework and other related posts if you haven’t already.
Sam does need pain meds of some sort and he does not need to rush into surgery based on what you have told me. X rays won’t show torn ligaments, however they will show clouding in the joint which just tells us what we already know, that there is joint disruption and damage.
See the post I just made on the wordpress blog regarding Clark, the hip dog.
And here are more answers now that I have some time:
I will always do a paid phone consult, so if you are interested, let me know and we will set that up.
I do not know of anyone else that practices the way I do, with standard therapy interventions and certification within veterinary medicine (CCRP) yet using the tried and true, long-standing principles of athletic training and strength training protocol. There are a few people in the U.S. that I know of who also carry the strength and conditioning certification that I do, the CSCS®.
The protocol for dealing with this situation did not exist that I could find when I first came into companion animal practice, in 2004-05. I began writing simple programs based on my background and experience. These have been refined and honed and proved to be beneficial.
Additionally I was blessed with a Great Dane companion for 10.5 years who was bone-on-bone in both knees, had all three ligaments torn in the right knee and two torn in the left. She had a genetic bone disorder called OCD (for short), and had two TPLO’s that didn’t work out, or, the end result was not what we would have aimed to accomplish. I am not anti-surgery and not because of her situation. It is through her situation that I learned even more about improving function non-surgically or in the face of very complicated circumstances.
At the least, I have substantiated with some vets in this area and around about (who have inquired and followed my simple homework) the beneficial effect of slow, weight-bearing, pain-controlled return to function after surgery. I built my Grace’s thigh muscles to better support her joints, and I had plenty of opportunity to see the benefits of increased muscle mass in her case. I have also appreciated the benefits in other cases.
I hope that you have found many of the other answers you were seeking elsewhere in this blog. I suggest pretending like it all just happened and start at the beginning of my homework suggestions (under “homework”) and I strongly suggest, as I said previously, that you obtain an anti-inflammatory if Sam’s system will support it (your vet will do blood work to substantiate this), and if not an nsaid, then use Tramadol or Gabapentin. There are lots of options for pain control (see my Q&A post regarding limping after surgery), and if you just pretend like it happened recently and really start again at the beginning, building up from there, I really think you will realise great benefit for Sam.
Adequan seems to work really well on relatively few dogs (animals). I tried it a lot in my Grace, and I was working with a surgeon friend, so we tried it three different ways (IM, IA, SQ)on three different trials, to no effect for her. Some of my clients say it has helped their dogs substantially. A surgeon on the East Coast told me in 2005 that he didn’t think it would work for my Grace and that they had stopped using it in horses due to little effect. It’s expensive, yes, and it’s great if it works on your dog.
In the meantime use fish oil and a glucosamine/chondroitin/msm combo for joint health. Your vet may carry these products. I have info posted elsewhere regarding these supplements. If Sam takes off running and injures the joint, then make him rest for the remainder of the day and he has to go back to slow leash walks until he is no longer lame. You may also use ice, right on his knee, 20 min, when he has a limping/lameness episode. Hopefully you will be able to have a veterinary relationship where more pain medicines are utilised for greater overall benefit. Check out www.ivapm.org for more pain management info. I’m with you in that he is probably uncomfortable at night. Pain meds will help this, and the other options I gave you will help it some.
If he were my dog, I would definitely follow my homework and the supplement advice, the pain med advice, and I’d recheck with me when the first four weeks of homework are completed. I would not have surgery on him right now based on what you have told me, however I also have seen older dogs do well in surgery…so it’s not the surgery that is offputting; it’s just that I think he can thrive, based on what you have told me, without surgery. You have opportunity to find out if you get strict with the restrictions and homework again. He will have difficulty every time he spazzes out until he builds more thigh muscle. Then the joint should suffer less impact. At the least, if you follow this simple homework, it could serve as pre-hab, and if you decide on surgery, he will be in better shape and presumably recover better after surgery.
That is all I have time for right now.
Our next consult should be a paid phone consult if you’d like to go further. Thanks for presenting Sam to us-
Exercise is thought to have beneficial effects on Parkinson’s disease. Jay L. Alberts, Ph.D., neuroscientist at the Cleveland Clinic Lerner Research Institute in Cleveland, saw this firsthand in 2003 when he rode a tandem bicycle across Iowa with a Parkinson’s disease patient to raise awareness of the disease. The patient experienced improvements in her symptoms after the ride.
“”The finding was serendipitous,” Dr. Alberts recalled. “I was pedaling faster than her, which forced her to pedal faster. She had improvements in her upper extremity function, so we started to look at the possible mechanism behind this improved function.” As part of this inquiry, Dr. Alberts, researcher Chintan Shah, B.S., and their Cleveland Clinic colleagues, recently used fcMRI to study the effect of exercise on 26 Parkinson’s disease patients.”
The above is a quote from an article regarding research looking at the benefits of exercise for Parkinson’s patients, found on Science Daily dot com, and as I read it this morning, I thought it to be a perfect example of the practice protocol I have developed that has proved beneficial for several orthopedic conditions in lieu or surgery…whatever reasons one might have for not having surgery performed on their pet.
I am one person working alone, however I have over 30 years background and experience in principles of human sport science, exercise physiology, program design, and the like. There are others with similar backgrounds working in veterinary rehabilitation. I began using simple principles based on years of experience, and I’ve seen much success, as evidenced by improved quality of life, improved function, and veterinary professional confirmation.
I don’t have money to drive clinical research, and while I have ideas of those whom I could approach to get involved with this research, I am busy in my practice and haven’t wanted to take the time aside to pursue grants or corporations. At some point I intend to write more about the beneficial outcomes and to further discuss cases, however in the meantime, take the first paragraph as affirmation that science is observation of a particular outcome or experience as well as the steps to prove what we imagine/postulate/thought we observed.
It has been proved anecdotally time and again that when the conservative and slowly progressive non-surgical interventions I have outlined in the homework discussions on this site and/or in my books are followed within the parameters I outline, improvement of the condition ensues, barring extenuating circumstances. I do not see the discussion as being whether surgery or no surgery is better; I present the protocol I use as beneficial guidelines instead of not giving a program of recovery to those who choose to wait or altogether forego surgery for some conditions.
In other words, for injuries and conditions that are not “life or death”, the fact is there are very many people who will not choose surgery for their pet (or for themselves, for that matter). The instead-of-surgery protocol I develop and use fills a need to help the pet recover.
Keep moving forward; there is no time constraint on the “one step at a time” methodology…you can always begin, again, now.