CRUCIATE DISEASE

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What is the CCL?

The cranial cruciate
ligament, or CCL, is an important support structure in the
knee of the dog. It runs between the femur (thigh bone)
and the tibia (shin bone), preventing excessive movement
between the two bones.
The CCL is made of dense connective tissue, with poor
ability to heal once the ligament has been injured. With
injury, the tibia and femur are less stable in relation to one
another, and that instability can lead to pain and further
injury.

Cranial Cruciate Disease in Dogs

In dogs, a CCL tear is rarely a sudden, acute injury like the ACL tears often seen in human athletes. Instead, it is typically a symptom of cruciate disease, characterized by a slow degeneration of the ligament that can begin months or even years before a complete tear occurs. This degeneration is often caused by factors such as joint injury, malfunction, or overuse, leading to inflammation and abnormal knee mechanics.

Common causes of cruciate disease include:

Concurrent luxating patellas
Hip dysplasia
Previous joint sprains
Hind leg conformation that increases impact on the knee
Obesity or excess weight, which puts additional stress on the knee joint
Age-related degeneration of the ligament
Immune-mediated disorders that cause inflammation in the joint

As the CCL slowly frays, dogs often develop scar tissue that helps stabilize the knee joint, minimizing the instability that might accompany an ACL tear in humans. However, regardless of the rate at which cruciate disease progresses, the end result is similar:

Inflammation in the joint and joint capsule
Potential for meniscal tears
Degeneration of cartilage and joint fluid
Long-term pain and dysfunction in the knee joint
Osteoarthritis development, leading to chronic pain and reduced mobility
Muscle atrophy due to decreased use of the affected leg
Compensatory injuries to other joints, such as the hip or opposite knee, due to altered gait and weight distribution
Decreased quality of life and difficulty performing daily activities

While sudden, complete CCL tears can occur in dogs, they are far less common than the gradual degeneration associated with cruciate disease.

How do we diagnose cruciate disease?

Diagnosing CCL (Cranial Cruciate Ligament) disease in dogs can be complex due to the varying degrees of joint health and instability among patients. Veterinarians typically rely on the "cranial drawer test" to assess instability and pain in the knee joint. This test involves manipulating the tibia (shin bone) forward relative to the femur (thigh bone) to check for excessive movement, which indicates a torn or damaged CCL.

In addition to the cranial drawer test, veterinarians specializing in sports medicine and rehabilitation may employ various other clinical tests to evaluate the extent of the injury, severity of pain, degree of instability, and potential involvement of the meniscus (a cartilage structure within the knee joint). Meniscal tears can cause more pain than a CCL injury alone.

To gain a more comprehensive understanding of the condition, veterinarians may recommend imaging techniques such as x-rays, musculoskeletal ultrasound, or MRI (Magnetic Resonance Imaging). These tools can help visualize the internal structures of the knee joint, assisting in the accurate diagnosis and treatment planning for cruciate disease or tears in dogs.

What about surgery for Cruciate disease?

In humans, surgical repair of the ACL (Anterior Cruciate Ligament) is a common recommendation following an injury. Patients usually undergo several weeks to months of physical therapy before surgery to improve post-operative outcomes. However, in humans, ACL tears are typically traumatic and do not involve long-term joint degeneration.

In dogs, surgical repair of the CCL is more complex due to the degenerative nature of the joint. Direct repair of the CCL is not possible, so veterinary surgeons have developed alternative surgical options that aim to reduce joint instability by altering the bone mechanics around the joint. These procedures are generally recommended for dogs with moderate to severe instability and can be discussed with a rehabilitation practitioner or specialized surgeon.

Meniscal injury is another concern in dogs with CCL disease. The meniscus, a thick piece of cartilage that helps stabilize the knee joint, is more susceptible to injury when the CCL is damaged. A torn meniscus causes ongoing pain that is harder to control without surgery and can lead to a more challenging recovery. Surgical debridement (removal) of the damaged meniscus is an option for these patients, either in combination with surgical stabilization or as a standalone procedure.

Non surgical modalities

Non-surgical modalities are not only options but are essential for the long-term health of the knee joint in dogs with CCL disease, regardless of whether they are combined with surgical intervention. The degenerative nature of the knee joint in these cases can lead to chronic pain, cartilage damage, and arthritis. The primary goal of non-surgical treatment is to address these issues and manage any joint instability present in the patient.

Because each patient is unique, the best approach is to tailor non-surgical (and surgical!) modalities and interventions to the individual needs of the dog, considering both the pet's requirements and the owner's preferences. A personalized treatment plan can help optimize the dog's comfort, mobility, and overall quality of life while managing the long-term effects of CCL disease.