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THE REFERRAL PROCESS
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Physiotherapy Management for the Luxating Patella (dislocation of the knee cap)

 
The stifle (knee) joint in the dog is made up of the femur (thigh bone), tibia (shin bone), fibula, patella (knee cap), patellar ligament (middle), medial and lateral (inside and outside) patellar ligaments, medial and lateral collateral ligaments, cranial and caudal (front and rear) cruciate ligaments and the meniscus. The latter three structures are inside the stifle joint.

Figure 1. The Stifle Joint
(http://www.heinescientific.com/en/70/veterinary-medicine/canine-knee-with-ligaments.html)

The patella is an important component of a normal functioning stifle which should sit within a groove (the trochlear groove) on the front face of the femur. The patella acts as a lever and pulley system to extend the stifle. The quadriceps tendon and the patellar ligament attach the patella to the quadriceps and tibia respectively. The medial and lateral patellar ligaments help maintain the patella within the trochlear groove.

When the patella is luxating, it comes out of the trochlear groove whilst the leg is in motion. The patella can luxate to the inside (medial patellar luxation) in approximately 90% of cases or to the outside (lateral patellar luxation) in the remaining 10% of cases.

Patellar luxation is a developmental congenital defect, often affecting both stifles, and is usually caused by:
a.   A trochlear groove that is too shallow
b.   A weak or stretched medial or lateral patellar ligament
c.   The lower attachment of the patellar ligament being too far to the inside of the tibia (medial patellar luxation)
Normal alignment
Figure 2. Normal alignment versus patellar luxation (http://pomeranianklubben.no/sykdommme/)

It is believed that the above points are caused by malalignment of the limb that occurs during growth and development. Very rarely, patellar luxation can be caused by direct accidental blunt injury to the knee and medial or lateral patellar ligaments.

There is an increasing incidence of patellar luxation in Flat-coated Retrievers but do you know what signs to look out for?
a.   Locking up at trot or canter which has developed as your dog has matured and may first look like the dog is skipping. There is usually no sign of pain despite the dog holding the leg off the ground for a few steps before returning it to normal without concern.
b.   There may be a popping sound when the dog is shifting/ moving around nearby or on its owners lap.
c.   Abnormal sitting posture with the stifle placed outward.
d.   Pain and lameness may exist in chronic cases where there has been wear of the patella cartilage against the femur causing osteoarthritis.

When an abnormal gait, lameness or inactivity of the affected limb is observed as a result of patellar luxation, surgery is indicated.

 
Post Surgical Management Patellar Luxation

If your dog has undergone surgery for patellar luxation, exercises may be recommended for you to perform on your pet, up to three times daily, in order to enhance their recovery. It is strongly recommended that a Chartered Veterinary Physiotherapist assesses your dog to advise you on the stages of rehabilitation as this programme may need to be modified to prevent surgical failure or complications.

Acute Stage (0-5 days post surgery)

Ice: Apply an ice/cold gel pack in a damp t-towel to the stifle for 10 minutes, two to four times daily, to reduce heat and inflammation of the joint, especially for the first 72 hours.
Effleurage: starting at the toes, with your fingers together, slowly push up with a medium pressure towards the ankle, knee, to the bottom and over and around into the groin region to facilitate lymphatic drainage and blood circulation and reduce local swelling. Repeat for 60 seconds.
Passive Range of Movement Exercises: to maintain or restore normal range of movement in the affected joints and prevent joint contractures. These are best performed with your pet in side lying. Following surgery, these exercises may be uncomfortable or your pet may show some anxiety. Let your animal’s comfort be your guide.

1.   With one hand in front of the stifle (knee) and one hand behind the tarsus (hock or ankle), slowly bring the knee up towards the spine and slowly extend the hip out backwards to point of comfort only. Repeat this 10 times.

       

 

       

2.   With one hand in front of the knee and one hand behind the ankle, slowly bend the knee taking the ankle towards the bottom bone and slowly straighten. Repeat this 10 times.

         

 

         

Husbandry Advice: NO impact activities i.e. jump on/off sofa or bed, up and down stairs, jumping in/out of car. NO slips or trips. No playing with or without other dogs.
Walks: recommended 3 x 5 minutes daily lead only encouraging weight bearing of the effected leg by walking very slowly. This is otherwise known as a toilet walk.

 
Sub-acute Stage (5 days – 3 Weeks post surgery)

Contrast therapy: Heat may be used to increase blood flow to enhance tissue healing and reduce joint stiffness. This may be done using a heat pack or wheat bag for 10-15 minutes. Use towels to moderate the heat output and check on your own skin prior to application on your pet to prevent burning the skin. Apply an ice/cold gel pack in a damp t-towel to the stifle for 10 minutes after treatment to reduce heat and inflammation of the joint.
Kneading Massage (Affected Leg): to increase the blood flow and warm up the muscles in preparation for passive movement and active exercises. For the hamstrings (back of thigh bone) and quadriceps (front of thigh bone), using your fingers behind the muscle and thumb on top of muscles from where you are sitting, perform slow, medium pressure, circular movements up and down the muscle groups. For the gluteals, fingers only and together starting at the bottom bone, small circular movements up towards the back and over the muscles alongside the spine. 60 seconds for each muscle group. 

         

 

           

Passive Range of Movement Exercises (as above)
Stretching Exercises:

1.   With one hand in front of the knee and one hand behind the ankle, take the leg back very gently (in line with the body) to stretch the front of the hip. Hold 30 seconds. Repeat 3 times.

         

2.   With the hands as above, slowly and gently take the thigh until it is horizontal with the spine and straighten the knee to stretch the back of the thigh (hamstrings). Hold for up to 30 seconds. Repeat 3 times.

 
         

Strengthening Exercises:
1.   Ask the patient to stand from sitting, encouraging square sitting by placing the limbs flexed underneath the patient. Repeat 5-10 times three times daily.

         

2.   In standing with both hind feet on the ground, slowly push over the bottom muscles to encourage patient to push back against you. Hold this for 10 seconds, repeat 5 times left and right.

 
         

Walks: recommended 3 x 10 minutes daily lead only at two weeks, encouraging weight bearing of the effected leg by walking very slowly.

 

Intermediate Stage (3-6 weeks post surgery)

Kneading massage, passive range of movement, stretching and strengthening exercises, if required, as above
Strengthening Exercises:
1.   3 leg standing - with one hand lightly supporting under the stomach and the other hand raising the good hind limb, encourage the patient to bear the weight on the standing limb for 10 seconds, repeat 5-10 times.

         

2. Place the patient’s two front legs on a low step to increase the load on the hind limbs. Maintain this position for 30 seconds and repeat 3 times.

3. From 4 weeks 2 leg standing – first raise the forelimb on the same side as the operated limb, then raise the diagonal un-operated hind limb and encourage the patient to hold this for up to 10 seconds. Repeat this 5-10 times.

           

Walks: recommended 3 x 10 minutes daily lead only encouraging weight bearing of the effected leg by walking very slowly. Add 5 minutes to each walk per week remaining on the lead i.e. 15 minutes in week 4, 20 minutes in week 5 and Check X-ray is usually recommended at week 6 before further progression is made.

Post X-ray (6-9 weeks post surgery)

Strengthening Exercises:
1.   Place 5-6 poles 8-18 inches apart from each other (allowing one hind footfall between two poles) and encourage the patient to step over these 6 times. To increase difficulty raise the poles 3-4 inches from the ground to encourage flexion of the stifle and increase the distance slightly to encourage full extension of the stifle. Progress into trot at week 9.

             

2. From 6 weeks (NOT if inflammation of the patellar tendon is suspected) Supervised steps – with lead control, walk up and down 3-4 steps, increasing the number gradually to a flight and repeat 6 times. It is important that the patient does not scoop his limb outwards as he/she steps up or down to avoid flexing the stifle.

3. Add gentle inclines, gradually increasing, into your walk exercise.

Walks: Add 5 minutes to each walk per week remaining on the lead.

Water Treadmill Hydrotherapy: this will assist with quadriceps strengthening and regaining normal stride length. Please contact your Veterinary Surgeon for details of local members of the Canine Hydrotherapy Association (CHA) or alternatively, view their website www.canine-hydrotherapy.org

Return to Play Stage (9-12 weeks post surgery)

Running straight off lead work. Preferably the dog should be walking for up to one hour before off lead work begins. It is advised that the patient is let off the lead at the end of a walk in a controlled and calm environment to avoid being over excitable. (Approx time scales to begin off lead 8 weeks if dog not excitable, 12 weeks if excitable)

Keeping your dog on the lean side is a good idea, since excess body weight stresses the joints, and it’s also a good idea to give your dog glucosamine supplements to support joint health.


Conservative Management of Patellar Luxation

This will vary according to the type and grade of luxation that your pet has. Here are some exercises, performed once daily, that can help improve the stability of the knee if your dog has been diagnosed with patellar luxation.

1.   Stand from square sitting. Repeat three sets of 10 repetitions
2.   Walk up/down 3-4 steps increasing gradually to a full flight. Repeating this 6 times
3.   Walk (on lead if required) up/down hills for 5-10 minutes as part of the normal exercise routine
4.   Place 5-6 poles 8-18 inches apart from each other (allowing one hind footfall between two poles) and encourage the patient to step over these 6 times. To increase difficulty raise the poles 3-4 inches from the ground to encourage flexion of the stifle and increase the distance slightly to encourage full extension of the stifle
5.   Water Treadmill Hydrotherapy

For further advice on the conservative management of patellar luxation and progression of the suggested rehabilitation programme, find you nearest Chartered Physiotherapist (ACPAT Category A) by visiting www.acpat.org

 


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