Should We Be Rehabbing Like Dogs and Horses? Rethinking Early Mobilization

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Have you ever watched a dog or horse heal from orthopedic surgery? They don’t do it like we do it. There are no crutches, big braces, or little scooters. In fact, early weight-bearing on the area is the only rule of thumb. So while we’re still totally disabled, our canine and equine buddies are already running around. While much research has been done on all of this, a new study continues to support that human orthopedic surgery has it backward. Let’s dig in.

My Dogs and Surgery

I love large Alaskan malamutes. Maybe it’s my love of the Colorado mountains, but if there ever was a prototypical mountain dog designed to live in the wild, it’s the domesticated wolf breed also known as a Malamute.

Many years ago one of our males tore his ACL. What I witnessed was super fascinating. This was a huge surgery where they reshaped bone and while he went down hard for a few days to maybe a week, the moment he could bear weight on that limb he was up. From there to light running was amazingly fast. In fact, he was back to normal activities by the time a human ACL patient was just getting off crutches. That’s when I began to wonder, did human orthopedic surgeons have it all backward? What if the accouterments of surgery like crutches, braces, casts, and scooters were all not needed? What if it’s more a placebo than required?

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Horses

I remember when I first spoke to a veterinarian who was one of the first to perform microfracture surgery in horses. This is a procedure also common to humans where holes are poked through the bone. The goal is to get bone marrow stem cells to flow into a spot that has lost cartilage and prompt the body to heal that spot.

The human version of the surgery was a really big deal. It requires patients to be on crutches after the surgery and even before that, they’re in bed with a continuous passive range of motion (CPM) device. For example, this keeps their knee moving while the area with the holes heals.

When I learned that the vet also did microfracture surgery, I asked how he handled the post-op rehab because I wasn’t sure how you would put a horse on crutches or CPM. He chuckled. They simply put the horse in the stall and it got up when the anesthesia wore off. While they would try to restrict the horse from workouts, they did nothing else, because immobilizing a horse could cause other problems. So here the horse was placing weight on the area right away. Despite this drastic difference between the equine and human procedure, the horses did very well.

The Achilles Tendon

In the new study, 135 patients who had an Achilles tendon surgical repair were randomized to one of two groups (1). The traditional surgery group was placed in a cast for two weeks and then a brace with heel lifts, that were gradually removed. This group wasn’t encouraged to place weight on the area for the first two weeks. The early mobilization group was placed in a special brace and encouraged to walk right away as tolerated.

At 6 months, the early mobilization group did better than the usual “keep weight off the area” approach. Hence, this study tends to support the veterinarian model. Get them up early as they can tolerate it!

This isn’t even a new idea. A 2017 review showed the same thing with Achilles surgery (2). The same thing happens with knee and hip replacement, early mobilization means sooner discharge from the hospital (3,4).

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Why We Use this Up Early Approach

Many of my colleagues have adopted the orthopedic model of keeping patients off of the areas where orthobiologic injections are placed. However, because of the research, I have reviewed here, we have always promoted what I call “Activity as Tolerated”. This means that the patient can often get back onto the injected area when their body tells them it’s time. That’s usually when the pain caused by the procedure has fallen to a 2/10 or below.

The upshot?  We should be focusing on getting patients back to placing weight on the areas we treat as soon as they can. Veterinarians have known for decades that this method works! It just took human doctors a little longer to get there.

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References:

(1) Aufwerber S, Heijne A, Edman G, Silbernagel KG, Ackermann PW. Does Early Functional Mobilization Affect Long-Term Outcomes After an Achilles Tendon Rupture? A Randomized Clinical Trial. Orthop J Sports Med. 2020;8(3):2325967120906522. Published 2020 Mar 16. doi:10.1177/2325967120906522

(2) Kauwe M. Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation. Clin Podiatr Med Surg. 2017;34(2):229-243. doi:10.1016/j.cpm.2016.10.009

(3) Okamoto T, Ridley RJ, Edmondston SJ, Visser M, Headford J, Yates PJ. Day-of-Surgery Mobilization Reduces the Length of Stay After Elective Hip Arthroplasty. J Arthroplasty. 2016;31(10):2227-2230. doi:10.1016/j.arth.2016.03.066

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