How I Treat PostOp TPLO with Physical Rehabilitation
World Small Animal Veterinary Association Congress Proceedings, 2018
Janet B. Van Dyke, DVM, DACVSMR
Canine Rehabilitation Institute, Inc.
Wellington, FL, USA

Canine rehabilitation is the application of physiotherapeutic techniques to evaluate and treat musculoskeletal impairments in our canine patients. It incorporates the use of objective outcome measures (goniometers, girthometers, etc.), manual assessments (including palpation, joint glides, and neurological assessment), gait analysis, and special tests brought from the field of human physiotherapy. This allows the therapist to tease out the specific structure and tissue type causing the impairments. The therapist evaluates the presenting complaint, subjective information from the owner, and objective assessment carried out during the examination to create a problem list. Each item on the problem list is addressed in the plan of care. Therapeutic plans generally involve a combination of manual therapies (joint mobilizations and soft tissue mobilizations), physical modalities (laser, therapeutic ultrasound, e-stim, shockwave), and therapeutic exercises. The modalities are generally used to prepare the tissues for the manual therapies and therapeutic exercises. Physical modalities should never be the sole therapeutic method applied to any patient. Therapeutic exercise plans are based upon the weight bearing status of the patient, with early interventions focusing upon functional weight bearing exercises, later progressing to functional strengthening exercises. All exercise plans incorporate proprioception, balance, strength, flexibility, and endurance. Exercise equipment includes physioballs (shaped as rolls, peanuts, eggs, donuts, and balls), cavaletti poles, therapy band, rocker/wobble boards, and treadmills. Physical modality parameters are chosen based upon the acuity of the injury. They are used to prepare the tissues for additional therapy and can generally be applied by trained veterinary nurses. The most commonly used physical modalities include neuromuscular electrical stimulation, laser, therapeutic ultrasound, extracorporeal shock wave therapy, and ice/compression units. When the postoperative TPLO patient presents to rehabilitation in our practice, the patient is still recovering from anesthesia. We assess the patient thoroughly, and using the objective data, create a problem list. For the typical TPLO patient this list will appear as follows:

  • Pain
  • Muscle atrophy
  • Skin incision
  • Joint swelling
  • Osteotomy
  • Implant
  • Decreased ROM:
    • Stifle and tarsus
  • Hip flexor shortening

From this problem list, we create a narrative or assessment: 9-year-old M/I Golden Retriever with 4-week history of LPL lameness presents immediately postop with:

  • Pain
  • Atrophy of the muscles of the thigh and crus (mild)
  • Skin incision (staples), joint swelling with heat
  • Radiographic evidence of osteotomy repaired with plate and screws
  • Decreased ROM - stifle (loss of approximately 25 degrees of flexion compared to r side) and tarsus (loss of 25–30 degrees of flexion compared to R side)
  • Loss of flexibility in hip flexors (moderate compared to R side)

This assessment provides the framework from which the therapist creates the treatment plan, based upon the functional goals for this patient. We may wish for ‘normal’ ROM for all joints in our patients, but for many, this is not a functional or achievable goal. For the 9-year-old Golden Retriever in this example, moderate OA in hips, stifles, and tarsi might preclude his obtaining ‘normal’ ROM. The therapist’s goal for this patient is to reach ROM’s that are functional and realistic. In our example here, the functional goals would be:

  • Pain control
  • Symmetrical muscling
  • Healed skin incision
  • Elimination of joint swelling
  • Healed osteotomy
  • Functional rom in stifle and tarsus
  • Functional flexibility at the coxofemoral joint

The treatment plan to achieve these goals will address each goal separately. Pain control will be addressed through use of TENS and cold compression. These will be applied immediately postoperatively. Once pain is controlled, muscle atrophy can be addressed using NMES to create co-contractions of the quadriceps group and the hamstrings simultaneously, so no joint motion occurs during this acute phase. The skin incision is treated with laser daily to speed healing, and cold compression is applied to prevent swelling and pain. Joint swelling is addressed via manual therapies, specifically Grade 1–2 joint mobilizations. NMES and laser are used to decrease swelling as well. The osteotomy is treated via extracorporeal shock wave therapy prior to extubation, repeated at the time of suture removal, and again at the 4-week postop visit when initial radiographs are obtained. Weight bearing across the osteotomy is encouraged via early weight shifting exercises. Range of motion issues are treated using manual therapies. The stifle is treated with Grade 1–2 joint mobilizations until the swelling and discomfort are resolved. Grade 2–3 mobilizations are then applied as needed. Therapeutic exercises to increase ROM include work over cavaletti poles. Tarsal ROM issues in TPLO dogs can be more challenging to resolve due to their often long-standing nature. Here, Grade 3–4 joint mobilizations are employed to gain joint capsule lengthening. Hip flexor shortening is treated via stretches and soft tissue mobilization techniques to the iliopsoas, tensor fascia latae, and rectus femoris. In conclusion, treating postoperative TPLO patients requires a thorough evaluation of their orthopedic as well as soft tissue impairments, creating a problem list, generating a list of functional goals for each of the impairments, and carrying out a treatment plan that addresses each of the goals. The temptation is to look for ‘protocols’ to treat these commonly-seen patients, however, each patient recovers at their own rate, and they do not ‘read the book’ on how fast they are ‘supposed’ to reach each level of recovery. Creative problem solving, attention to detail, and focusing upon creating and meeting goals that are functional for each patient will result in superior results.


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Janet B. Van Dyke, DVM, DACVSMR
Canine Rehabilitation Institute, Inc.
Wellington, FL, USA

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