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1 CONSERVATIVE+MANAGEMENT+OF+CRUCIATE+LIGAMENT+DEFICIENCY+WITH+PHYSICAL+THERAPY+ LaurieEdge5Hughes,BScPT,MAnimSt(AnimalPhysiotherapy),CAFCI,CCRT TheCanineFitnessCentreLtd,Calgary,Alberta,Canada Presented(at(the(5 th (International(Symposium(on(Rehabilitation(and(Physical(Therapy(in(Veterinary( Medicine,(St.(Paul,(Minnesota,(2008.( ( Allpractitionersinvolvedinsmallanimalhealthcarearewellawareofthefactthatsomeanimals arenotsurgicalcandidates,eitherduetoage,poorhealth,aninadequatestateoffitness,and/or because of financial constraints,orowners beliefs.thissubsetofpatientsdeservesachanceat optimalfunctionasmuchasthosethatareprimesurgicalcandidateswithownerswillingandableto bearthefinancialburdenofsurgery. The+Cruciate>Deficient+Canine+Stifle+ Thecranialcruciateligamentfunctionstopreventexcessivecranialtranslationofthetibiarelativeto thefemuraswellaslimitinginternalrotationofthetibia.(hulse1995)indogs,themechanismof injuryresultinginarupturedcranialcruciateligament(rccl),canbefromasingleincidentifthe breaking strength of the ligament is exceeded.(johnson & Johnson 1993) However, other dogs suffer from a RCCL with only mild trauma.(moore &Read1996)Etiologyinthelattergroupof patientsissuggestiveofdailymechanicalwear,anddegenerativechangesaswellasunsuccessful attemptsatbiologicalrepairhavebeenreportedinthefibresoftherccl.(vasseur1985;krayeretal 2008)Wilkeetal2006wasalsoabletoestablishageneticbasisforRCCLinNewfoundlanddogs, and others have found a high prevalence of RCCL in this breed as well as Rottweilers and StaffordshireTerriers.(Whitehairetal1993)Additionally,abreedpredispositionwasdetectedfor Neapolitan Mastiff, Akita, Saint Bernard, Mastiff, Chesapeake Bay Retriever, and Labrador Retriever.(Duvaletal1999)Neutereddogs,whethermaleorfemale,hadahigherprevalenceof RCCLthandidsexuallyintactdogs,anddogsweighing>22kghadahigherprevalenceofRCCLandat ayoungeragecomparedwithdogsweighing<22kg.(whitehairetal1993)obesityhasalsobeen reportedasacontributingfactor.(johnson&johnson1993) In the case of cruciate5deficiency, the stifle of the canine patient exhibits an increase in synovial macrophagedensity,andsynovialfluidbiomarkersofcartilagedisease(i.e.osteoarthritis).(inneset al1999;johnsonetal2002;klockeetal2005;sprengdetal2000)thechronologyofdegenerative events in the cruciate5deficiency follows through the stages of cartilage fibrillation, periarticular hypervascularity, osteophyte development, medial joint swelling, periarticular fibrosis (restabilization), meniscal injury, peak osteophyte formation and synovitis, settling synovitis, articular cartilage erosion, collagen fibril network break5down, and finally, slowing of osteophyte formation.(johnson&johnson1993)however,followingrcclreconstruction,thereisanincrease intheglobalprogressionoftheosteoarthritisdiseaseprocess,proliferationofosteophytesandjoint effusion as well as notable quadriceps atrophy at 7 and 13 monthspostoperatively.(innes & Barr 1998;Innesetal2004)Contralateralstiflejointosteoarthritishasalsobeendetectedfollowinga unilateralcranialcruciateligamentrupture.(debruinetal2007)decampetal1996describedgait alterationindogsrccldogs.thestiflejointanglewasmoreflexedthroughoutstanceandearly swingphaseofstrideandfailedtoextendinlatestance.incontrast,thehipandtarsusweremore ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.

2 extendedduringstancephase,andtherewasanoveralllossofpropulsion.theauthorsofthisstudy notedthatmeniscalinjuryoccurredinseveralofthestudydogsby35monthsandcommentedthat fibrosisofthejointisinsufficientin6monthstoresultinjointstabilityandsignificantimprovement ingait. The+Cruciate+Deficient+Human+Knee+ Ascantamountofliteraturehasbeenpublishedspecificallydedicatedtoconservativerehabilitation ofcaninecruciate5deficiency.(vasseur1979)whilesomestudieshaveusedcruciate5deficientdogs as control animals, evidence5base rehabilitation programs are not generally part of standard managementprotocolsforacomparableevaluationofthisoption.humanliteraturehasattempted tomakecomparisonsbetweensurgicalandconservativemanagementofthecruciate5deficientknee andtostudyspecifictreatmentsandoutcomespertainingtotherehabilitationofthenon5operative kneejoint. Ciccottietal(1994)studiedtheEMGactivityofanteriorcruciateligamentdeficient(ACL5D)kneesas compared to normal and reconstructed knees at a walk. The same muscle activity was found in othermovementsaswell.thefindingsaredescribedintable1. Table+ 1:+ + EMG+ Activity+ in+ Muscles+ of+ ACL>D+ Knees+ as+ Compared+ to+ Normal+ and+ Reconstructed+ Knees+in+ Humans+ Muscle+Activation+ Increase in vastus lateralis activity at loading Increaseinrectusfemorisactivityatpre5 swing Increase in biceps femoris activity at terminalswing Increase in tibialis anterior activity at terminalstance Implication+ Vastuslateralisresistsinternalrotationofthetibia Thismayindicateadecreaseinkneeflexion Thismaybetopreventanteriortibialtranslationwithquadriceps contractionatloading Tibialis anterior creates a dorsiflexion and inversion which also externally rotates the tibia (hence resisting internal rotation forces) TheauthorsconcludedthatrehabilitationdoesnotrestorenormalEMGpatterns,yetsurgerydoes. They further postulated that there is likely a reduction in performance in ACL5D knees in more strenuoussports.theseresultsalsosuggestthatneuropathwaysotherthanthosemediatedbyacl mechanoreceptorsexisttocoordinatemuscleactivity.otherstudieshaveshownagreaterflexion angleinacl5dkneesduringcertainperiodsofstance.(wexler1998)quadricepsweaknesshasbeen identifiedascommonproblemafteraclinjury,andthisweaknesswaspersistentinpatientswith poorfunctioningknees.(tagessonetal2008)priortorehabilitationstrengthening,thesepatients didnotextendtheinjuredkneetothesameextentastheuninjuredknee.whileacertainamount of tibial translation is important to good functioning afteraclinjury(tagessonetal2008), symptomatic ACL5D patients exhibited more anterior displacement than those who were asymptomaticduringweightbearing.(fridenetal1993)yet,statictibialtranslationhasnotbeen found to correlate with functional outcome.(tagesson et al 2008) Several studies have shown significant proprioceptive deficits to affect both the cruciate deficient or surgically reconstructed knee as well as thecontralateralnormalknee.(robertsetal1999;fridenetal2001;fridenetal ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.

3 1999;Zatterstrometal1994;Robertsetal2000)Thereisacorrelationbetweenproprioceptive deficits and subjective knee function in patients with symptomatic ACL deficiency.(robertsetal 1999, Friden et al 2001) There is also a relation between the patient s ability to detect passive motionandmorphologicallesions(chondralormeniscallesions).(fridenetal1999) Rehabilitation+of+the+Cruciate+Deficient+Human+Knee+ Some papers report conservative treatment of human anterior cruciate ligament deficiency to be unsuccessfuloronlysuccessfulinolderorinactivepatients.(scavenius et al 1999;Strehl&Eggli 2007;Zysk&Refior2000;Bussetal1995)However,successfultreatmentofthenon5surgicalACL deficient knee has been shown to bepossiblewithspecifically targeted rehabilitation programs. Noyes et al (1983) proposed the rule of thirds for chronic ACL injuries treated with rehabilitation:1/3ofpatientscanresumepreviousrecreationactivitieswithoutreconstruction;1/3 manage without reconstruction by modifying or lowering their activity level; and 1/3 require reconstruction because of recurring giving way episodes even in activities of daily living. Thus creating 3 groups of patients: copers, compensators, and non5copers.(noyes et al 1983) ComparisonsofrehabilitatedACL5Dandnormalkneesforfunction(usingthesingleleghoptest)was foundtoresultin77ofthesubjectshavingnormalfunctionatoneyearpost5injury,89normalat 35years,and85normalat15yearsoffollowup.(Agebergetal2001;Agebergetal2007)Strength (isometricandconcentric)asmeasuredbythebiodexdynamometerwasshowntobenormalin42 56ofthesubjectsat1year,54 68at3yearsand69 82at15yearsfollow5up.(Agebergetal 2001;Agebergetal2007)Activitylevelschangewithrehabilitationmanagementandsurgical management of the ACL injured knee.(kostogiannis et al 2007)Table 2reflectsthedeclinein activitylevelsregardlessoftheinterventionusingthetegneractivitylevelscoringsystem. Table+2.++Tegner+activity+level+scoring+following+unilateral+ACL+injury+(median)+ Treatment+ Pre>injury+ 1>Year+Follow>up+ 3>Years++Follow>up+ 15>Years+Follow>up+ Rehabilitation+only Reconstruction+ Rehab+ & Thesamestudyalsocollecteddataonsubjectivekneefunctionscoring/qualityoflife(QOL)scoring. Patients scored the highest 1 and 3 years following injury in the rehab5only group, with patient injured in contact sports scoring the lowest as compared to those injured in non5contact sports.(kostogiannis et al 2007) Interestingly at the155year follow5up, those patient with reconstruction surgery scored lower in the QOL scores than the non5reconstructed patients.(kostogiannisetal2007)thissamecohortofpatientswasalsoevaluatedforevidenceof radiographicosteoarthritisatthe155yearmarkfollowinginjury.(neumanetal2008)sixteenpercent oftherehabilitatedpatientsdevelopedradiographicosteoarthritis(oa).allofthepatientswithoa hadundergoneameniscectomy.noneofthenon5meniscetomizedpatientsdevelopedoa.sixty5 eightpercentofthepatientsreportedtohaveanasymptomaticknee,while23reportedhaving reconstructive surgery at an average of 45yearsafterinjury.(Neumanetal2008)Myklebustetal (2003)foundthe91ofcompetitivehandballplayerstreatedwithoutreconstructioncouldreturn topre5injuryactivitylevel,whereasonly58inthereconstructedgroupwereabletodothesame. AreviewofliteraturebyCasteleyn(1999)concludedthatwhileACLreconstructionyieldedtheleast ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.

4 amount of secondary meniscal surgery, osteoarthritic morbity was higher compared with a conservativelymanagedgroup.sportsparticipationtendedtobehigherinthereconstructedgroup aswell.(casteleyn1999) Conservative+Rehabilitation+of+Cruciate>Deficiency+ SuccessfulmanagementoftheACL5Dkneeinhumanscentresonsomecommongoals:Earlyactivity modification, neuromuscular knee rehabilitation,andstrengthtraining.(agebergetal2007; Kostogiannis et al 2007;Neumanetal2008;Tagessonetal2008;Brotzman&Wilk2007)It is appropriatetostagetherehabilitationgoalsandactivitiesthroughrehabilitation.timealoneisnot thesignalforadvancementfromoneprogrammetoanother,andattentionshouldbepaidtorange of motion(rom), strength, fluidity of performance of functional activities as well as functional testing.(markey 1991)UsingthegoalsforeachphaseofrehabilitationofanACL5D human knee, treatment regimes can be proposed. Tables3 6illustratethegoalsandthisauthor s (LEH) suggestionsforrehabofthecaninepatientineachphase. Table+3.++Goals+and+Treatment+Suggestions+for+Phase+1+(Protection)+of+the+Canine+ACL>D+Stifle+ Phase+1:+Protection+(Weeks+1+ +4)+ Goal+ IncreaseROM Increase muscle function using movement synergies and utilizingmotorlearningtransfer Increaseproprioception Decreasepainandeffusion Suggestion+ PROM flexion and extension; tummy rubs into extension; square sitting practice. Active sitting down to astool(guidingrearlegsforsymmetryof movement);toepinches(alternatingandsimultaneous)insidelying;leash walking to toilet, progressing to 5 minutes and increasing time by 3 5 minutes per week (if no increase in joint inflammation); Weight shifting exercises; Balance board exercises (front legs on the board); Standing on soft surfaces and balance; 35leg standing; step ups; Walking in circles or figure5of58patterns. Jointcompressions;Grades1 2jointmobilizations. Icing;PROM&AROMwithinpaintolerance;jointcompressions;Grades15 2jointmobilizations;NMES;Modalities. Table+4.++Goals+and+Treatment+Suggestions+for+Phase+2+(Early+Strengthening)+of+the+Canine+ACL>D+Stifle+ Phase+2:++Early+Strength+Training+(Weeks+5+ +8)+ FullROM Normalgait Increase motor control (neuromuscular training) and strength Load: 50 60ofuninjured limb Asabove;mayaddtoe5touchhanging,orextensiononthestairs;mayadd sittingpracticeonastoolorplatform. Walking with a disturbance on the unaffected foot; Obstacle walkingor trotting;steepup5hillwalkingortrotting; Underwatertreadmillorswimmingexercise;NMESormanualtappingon quadriceps or gluteals with 35leg standing; NMES or manual facilitation on/ofhamstringswithsittingpractice;sidesteppingorbacksteppingover apole;steppingupbackwards;walkingbackwards;anyoftheaboveland exercisesonasoftsurface;hillwalking;stairwalking. Increasetimeanddurationofexercisesabove. ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.

5 Table+5.++Goals+and+Treatment+Suggestions+for+Phase+3+(Intense+Strengthening)+of+the+Canine+ACL>D+Stifle+ Phase+3:+Intense+Strength+Training+(Weeks )+ Increased strength, and motor control(neuromusculartraining) Increase Load: of uninjured limb (increasing by 10nearerendofstage) Continuemostchallengingexercisesfromabove;Walkingwithaweighton the affected leg (open kinetic chain training); Trotting up5/down5hills; Walkingonunevensurfaces;Recallrunningbetweentwopeople. Increase time and duration of exercises above; Perform exercises above withaweightpack. Table+6.++Goals+and+Treatment+Suggestions+for+Phase+4+(Intensive+strength+training+and+return+to+sports)+of+ the+canine+acl>d+stifle+ Phase+4:++Intensive+Strength++Training+and+Return+to+Sports+( weeks)+ Increasedstrength Increasedcoordination Increased ability in sport5 specificactivities Load 80 of uninjured leg (increasing by 10 nearer end ofstage) Continue most challenging exercises from above; Destination jumping exercisesfromastand(plyometrics). Agility5typetraining. Shortdistanceballretrieves;1or2agility5typepiecesofequipment;Avoid playwithotherdogsuntilcloserto6monthsorlongerandstartwithonly shortintervals. Increase time and duration of exercises above; Perform exercises above withaweightpack. Whilenaturalhealingofameniscaltearhasbeenreportedlypossible(Iharaetal1994),ameniscal injurymayinhibitsuccessofthisregimen.preventingosteoarthritisshouldbeanimportantgoalfor all animals that have suffered a joint trauma. Human studies have found a correlation with glucosamineuseandareductioninjointspacenarrowinganderosiveeffectsofoaoveraperiodof threeyears(bruyereetal2003;verbruggenetal2002).caninestudieshavefoundthattheuseofa glucosamine / chondroitin sulfate mixture can enhance synthesis and turn5over of the matrix of proteoglycansandcollagenandhencecanhaveaprotectiveeffectagainstsynovitisandassociated boneremodelling. (Johnsonetal2001;Canappetal1999)Cetylatedfattyacidshavealsobeen shown in both human and animal studies tomodulatetheimmuneresponseandinflammatory processofosteoarthritisandin5turnimproveromandoverallfunction(hesslinketal2002;curtiset al2002;richardsonetal1997).advisementonnutritionalsupplementationshouldbeconsidered just as important as physical management of the condition. Additionally excessive weight can impactthestressesonarticularcartilage.ahumanstudyfoundthateachpoundofweightlostwill resultina45foldreductionintheloadexertedonthekneeperstepduringdailyactivities(messieret al2005).acaninestudyfoundthatdogswithhipoathatwerefed60oftheircurrentcalorie intake lost 11 18oftheirbodyweightandexperiencedasignificantdecreaseinhindlimb lameness (Impellizerietal 2000). Weight management should be deemed an integral part of rehabilitationofthecruciate5deficientdog. Conclusion+ ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.

6 Good functional recovery following a cruciate ligament injury is possible with conservative management.olderanimalsandthosenotengagedinhighenergysportingactivitiesmighthavean acceptableoutcomewithconservativecare.additionally,animalswhoarenotsurgicalcandidates for whatever reason may benefit from this evidence5based proposal for the conservative managementofcruciatedeficiencyindogs. References:+ 1. Ageberg E, Pettersson A, Friden T et al. 155year follow5up of neuromuscular function in patients with unilateral nonreconstructed anterior cruciate ligament injury initially treated with rehabilitation and activitymodification.alongitudinalprospectivestudy.amjsportsmed35(12): , AgebergE,ZatterstromR,MoritzU,etal.Influenceofsupervisedandnonsupervisedtrainingonpostural controlafteranacuteanteriorcruciateligamentrupture:athree5yearlongitudinalprospectivestudy.j OrthopSportsPhysTher31(11): , Brotzman SB, Wilk KE. Handbook of Orthopaedic Rehabilitation, 2 nd Ed.MosbyElsevier,Philadelphia, BruyereO,HonoreA,EthgenOetal.Correlationbetweenradiographicseverityofkneeosteoarthritisand futurediseaseprogression.resultsfroma35yearprospective,placebo5controlledstudyevaluatingthe effectofglucosaminesulfate.osteoarthritisandcartilage11(1):155, BussDD,MinR,SkyharMetal.Nonoperativetreatmentofacuteanteriorcruciateligamentinjuriesina selectedgroupofpatients.amjsportsmed23(2): , CanappSOJr,McLaughlinRMJr,HoskinsonJJetal.Scintigraphicevaluationofdogswithacutesynovitis aftertreatmentwithglucosaminehydrochlorideandchondroitin.amjvetres(60(12): , Casteleyn PP. Management of anterior cruciate ligament lesions: surgical fashion, personal whim or scientificevidence?studyofmedium5andlong5termresults.actaorthopbelg65(3): , Ciccotti MG, Kerlan RK, Perry J et al. An electromyographic analysis of the knee during functional activities:ii.theanteriorcruciateligament5deficientand reconstructedprofiles.amjsportsmed22(5): , CurtisCL,ReesSG,CrampJetal.Effectsofn53fattyacidsoncartilagemetabolism.ProcNutrSoc61(3): , DeBruinT,deRoosterH,BosmansTetal.Radiographicassessmentoftheprogressionofosteoarthrosis inthecontralateralstiflejointofdogswitharupturedcranialcruciateligament.vetrec161(22): , DuvalJM,BudsbergSC,FloGLetal.Breed,sex,andbodyweightasriskfactorsforruptureofthecranial cruciateligamentinyoungdogs.jamvetmedassoc15(6): , Friden T, Egund N, Lindstrand A. Comparison of symptomatic versus nonsymptomatic patients with chronicanteriorcruciateligamentinsufficiency.radiographicsagittaldisplacementduringweightbearing. AmJSportsMed21(3): , Friden T, Roberts D, Ageberg E, et al. Review of knee proprioception and the relation to extremity functionafterananteriorcruciateligamentrupture.jorthopsportsphysther31(10): , FridenT,RobertsD,ZatterstromRetal.Proprioceptivedefectsafterananteriorcruciateligamentrupture therelationtoassociatedanatomicallesionsandsubjectivekneefunction.kneesurgsportstraumatol Arthrosc7(4): , HesslinkR,ArmstrongDIII,NagendranMVetal.Cetylatedfattyacidsimprovekneefunctioninpatients withosteoarthritis.jrheumatol29(8):pp , InnesJF,BarrAR.Clinicalnaturalhistoryofthepostsurgicalcruciatedeficientcaninestiflejoint:year1.J SmallAnimPract39(7): ,1998. ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.

7 17. HulseD.Thestiflejoint.InSmallAnimalOrthopedics.OlmsteadMLed.Mosby,StLouis, IharaH,MiwaM,TakayanagiKetal.Acutetornmeniscuscombinedwithacutecruciateligamentinjury. Second look arthroscopy after 35month conservative treatment. Clin Orthop Relat Res 307: , ImpellizeriJA,TetrickMA,MuirP.Effectofweightreductiononclinicalsignsoflamenessindogswithhip osteoarthritis.jamvetmedassn(216(7): , InnesJF,SharifM,BarrAR.Changesinconcentrationsofbiochemicalmarkersofosteoarthritisfollowing surgicalrepairofrupturedcranialcruciateligamentsindogs.amjvetres60(9): , InnesJF,CostelloM,BarrFJetal.Radiographicprogressionofosteoarthritisofthecaninestiflejoint:A prospectivestudy.vetradiolultrasound45(2): , JohnsonKA,HayCW,ChuQ,etal.Cartilage5derivedbiomarkersofosteoarthritisinsynovialfluidofdogs withnaturallyacquiredruptureofthecranialcruciateligament.amjvetres63(6): , JohnsonKA,HulseDA,HartRCetal.Effectsofanorallyadministeredmixtureofchondroitinsulfate, glucosaminehydrochlorideandmanganeseascorbateonsynovialfluidchondroitinsulfate3b3and7d4 epitopeinacaninecruciateligamenttransactionmodelofosteoarthritis.osteoarthritisandcartilage((9: 14 21, JohnsonJM,JohnsonAL.Cranialcruciateligamentrupture.VetClinNAmSmAnimPract23(4): , KlockNW,SnyderPW,WidmerWR,etal.Detectionofsynovialmacrophagesinthejointcapsuleofdogs withnaturallyoccurringruptureofthecranialcruciateligament.amjvetres66(3): , Kostogiannis I, Ageberg E, Neuman P et al. Activity level and subjective knee function 15 years after anteiro cruciate ligament injury. A prospective, longitudinal study of nonreconstructed patients. Am J SportsMed35(7): , KrayerM,RytzU,OevermannA,etal.Apoptosisofligamentouscellsofthecranialcruciateligamentfrom stablestiflejointsofdogswithpartialcranialcruciateligamentrupture.amjvetres69(5): , MarkeyKL.Functionalrehabilitationofthecruciate5deficientknee.SportsMed12(6): , MessierSP,GutekunstDJ,DavisCetal.Weightlossreducesknee5jointloadsinoverweightandobese olderadultswithkneeosteoarthritis.arthritisrheum52(7): , MooreKW,ReadRA.RupturesoftheCCLindogs part1.compendcontineducpractvet18: , Myklebust G, Holm I, Maehlum S et al. Clinical, functional, and radiologic outcome in team handball players6 11yearsafteranteriorcruciateligamentinjury:afollow5upstudy.AmJsportsMed31: , Neuman P, Englund M, Kostogiannis I et al. Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: A prospective cohort study. Am J Sports Med,May15(E5pubaheadofprint), NoyesFR,MatthewsDS,MooarPAetal.Thesymptomaticanteriorcruciate5deficientknee.PartII:the resultsofrehabilitation,activitymodification,andcounsellingonfunctionaldisability.jbonejointsurg Am65: , RichardsonDC,SchoeherrWD,ZickerSC.Nutritionalmanagementofosteoarthritis.VetClinNAmSm AnimPract27(4): , RobertsD,AgebergE,AnderssonGetal.Clinicalmeasurementsofproprioception,musclestrengthand laxityinrelationtofunctionintheacl5injuredknee.kneesurgsportstraumatolarthrosc15(1):9 16, Roberts D, Friden T, Stromberg A, et al. Bilateral proprioceptive defects in patients withaunilateral anterior cruciate ligament reconstruction: a comparison between patients and healthy individual. J OrthopRes18(4): ,2000. ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.

8 37. Roberts D, Friden T, Zatterstrom R et al. Proprioception in people with anterior cruciate ligament5 deficientknees:comparisonofsymptomaticandasymptomaticpatients.jorthopsportsphysther29 (10): , ScaveniusM,BakK,HansenS,etal.Isolatedtotalrupturesoftheanteriorcruciateligament aclinical studywithlong5termfollow5upof7years.scandjmedscisports9(2): , Spreng D, Sigrist N, Jungi T, et al. Nitric oxide metabolite production in the cranial cruciate ligament, synovialmembrane,andarticularcartilageofdogswithcranialcruciateligamentrupture.amjvetres 61(5): , StrehlA,EggliS.Thevalueofconservativetreatmentinrupturesoftheanteriorcruciateligament(ACL).J Trauma62(5): , Tagesson S, Oberg B, Good L et al. A comprehensive rehabilitation program with quadriceps strengthening in closed versus open kinetic chain exercise in patients with anterior cruciate ligament deficiency. A randomized clinical trial evaluating dynamic tibial translation and muscle function. Am J SportsMed36(2): , Vasseur PB. Clinical results following nonoperative management for rupture of the cranialcruciate ligamentindogs.vetsurg13:283, VasseurPB.Correlativebiomechanicalandhistologicstudyofthecranialcruciateligamentindogs.AmJ VetRes46:1842, Verbruggenetal.Systemstoassesstheprogressionoffingerjointosteoarthritisandtheeffectsof diseasemodifyingosteoarthritisdrugs.clinicalrheumatology(21:pp , WexlerG,HurwitzDE,Bush5JosephCAetal.Functionalgaitadaptationsinpatientwithanteriorcruciate ligamentdeficiencyovertime.clinorthoprelres248: , WhitehairJG,VasseurPB,WillitsNH.Epidemiologyofcranialcruciateligamentruptureindogs.JAmVet MedAssoc203: , ZatterstromR,FridenT,LindstrandAetal.Theeffectofphysiotherapyonstandingbalanceinchronic anteriorcruciateligamentinsufficiency.amjsportsmed22(4): , ZyskSP,RefiorHJ.Operativeorconservativetreatmentoftheacutelytornanteriorcruciateligamentin middle5agedpatients.afollow5upstudyof133patientsbetweentheagesof40 59years.ArchOrthop TraumaSurg120(152):59 64,2000. ThisinformationisthepropertyofL.Edge5Hughesandshouldnotbecopiedorotherwiseusedwithout expresswrittenpermissionoftheauthor.