Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018024
Abstract
REASONS FOR PERFORMING CASE STUDY: To evaluate if the suspected observed sequelae to the initial medial shoulder instability could be stabilized or healed with acupuncture and continued related techniques.
DESCRIPTION: A nine-year-old border collie was evaluated for a grade 4 left forelimb lameness of 4-year duration. The initial diagnosis was medial shoulder instability and had progressed to carpal hyperextension and a chronic wound of the left ventral carpus. Acupuncture had been added into the current therapies including photomedicine and long-term bandaging.
RESULTS: Acupuncture treatments appear to have stabilized the worsening progression of his carpal hyperextension and chronic carpal skin lesion.
History and Presentation: The patient is a male neutered, 9-year-old border collie that presented to me for examination in April 2015 after being recently adopted from an animal shelter. At that time, the owner was concerned about his left forelimb lameness. He has had this lameness since the owner adopted him. The patient’s previous history of possible trauma is unknown. On physical exam, he was found to have pain with left shoulder extension and extreme shoulder flexion when pressure was applied to the area of the biceps tendon. A sedated orthopedic exam and radiographs were performed. The sedated exam revealed a left shoulder abduction angle of 55 degrees compared to the normal right shoulder abduction angle of 25 degrees. Left shoulder abduction was also palpable when the shoulder was moved into extension. He was diagnosed with medial shoulder instability of the left forelimb and a grade 3 out of 5 left forelimb lameness. A custom-made shoulder stabilization system was ordered for the patient. His lab work was unremarkable and he was prescribed gabapentin, Adequan injections, omega 3 fatty acids and occasional tramadol if needed for additional pain relief. He also was prescribed alprazolam for occasional noise related anxiety. The patient presented again in February 2018 for a superficial wound to the left ventral carpal pad. The grade 3 left forelimb lameness was still present. The owner had not been using the shoulder stabilization system and was not concerned about the lameness as she did not think he was painful. She felt his quality of life was better when he was not wearing the system. The patient was on the same medications as previously prescribed with the addition of Rimadyl which was added in April 2016. The owner was most concerned about the skin wound and that the patient was consistently licking the site. He was bandaged and placed on antibiotics. The wound worsened to an abscess. The wound was cultured, biopsied and radiographs were taken. There was no sign of neoplasia or boney involvement seen. The culture result was sensitive to the current antibiotic. The antibiotics were continued for a period of 4 months. After the 4 months of antibiotics, the wound was improved but still present, and the patient would still lick occasionally. The laboratory bloodwork was normal. Treatments with the Companion Class IV laser (810 nm) were started twice weekly for 12 sessions at wound settings of total 196 J delivered over 2 minutes and 27 seconds continuous mode at 1.3 W. The skin lesion appeared healed. The lameness remained constant. The patient presented again on January 29, 2019 for recurring bleeding skin wound at left ventral carpal pad.
Physical Examination and Clinical Assessments: His vital signs were normal. Physical exam findings were normal besides his orthopedic and myofascial abnormalities. His neurologic exam was normal. He had myofascial tension in the dorsal scapular area and caudal cervical spine region. He had trigger points in the area of the biceps brachii, extensor carpi radialis and common digital extensor muscles. He had decreased flexion in both carpi, with the left being the worst. There was fibrous thickening of the tissues on the ventral carpus in the area of the carpal pad with an ulcerative wound in the center of this pad. This area of the main carpal pad was approximately two times as thick as the carpal pad on the opposite front limb. There was saliva staining from persistent licking the area of the wound. Gait analysis showed the left forelimb lameness has progressed to a grade 4 out of 5 lameness with moderate left carpal hyperextension and mild right carpal hyperextension. Shoulder abduction was not evaluated in this exam as it has already been diagnosed and didn’t want to risk stretching the tissues in this area. Radiographs of the carpi were taken to compare to previous views. Degenerative joint disease was seen in both carpi with the left moderately worse. The patient was placed into a forelimb/ carpal spoon splint for support. He was prescribed antibiotics and sent home with an Elizabethan collar. Options were discussed with the Owner including orthopedic surgeon consult for possible partial or panarthrodesis, carpal splinting or brace support, regenerative therapy (platelet rich plasma/stem cell injections) and medical management (laser, acupuncture and related therapy for pain management). Owner was not interested in carpal splinting or brace support. Owner had a custom-made shoulder stabilization system at home that she did not feel was helpful to this patient. Owner’s main concern was his chronic wound to his ventral carpus. Owner was interested in pursuing medical therapy to help ease discomfort in this area. The owner declined having the patient wear a collar to prevent licking as she felt it caused his anxiety to worsen. We removed the splint from the carpus at the next visit.
Problem List 1) Bilateral carpal hyperextension (left worse), 2) recurring wound on left ventral carpal pad, 3) medial shoulder instability- left (historical), 4) myofascial restrictions caudal cervical and dorsal scapula, 5) trigger points at tendon of biceps brachii region.
Differential Diagnoses for Top Two Problems: 1) Bilateral carpal hyperextension (left worse): Vascular causes include vasculitis, sepsis. Infectious causes include rickettsial, bacterial, osteomyelitis and fungal. Neoplastic causes include metastatic, lymphoma and paraneoplastic. Degenerative causes include neuromuscular and inflammation. Iatrogenic/Intoxication causes include neuro toxins and toxins causing inflammation. Congenital causes include joint deformity and congenital tendinopathy. Autoimmune causes include immune mediated arthropathy. Traumatic causes include previous unknown trauma to nerves, tendons or ligaments, joint luxation or subluxation, repetitive stress due to strain and instability. Endocrine/Metabolic causes include cushings, hypothyroidism, malnutrition and diabetes mellitus. Myofascial causes include restrictive tissue, referred pain and nerve entrapment. 2) Recurring wound on left ventral carpal pad: Vascular causes include vasculitis, sepsis, pressure lesion, insect bite and lick granuloma. Infectious causes include bacterial, osteomyelitis and fungal. Neoplastic causes include soft tissue sarcoma, carcinoma, metastatic and cutaneous lymphoma. Degenerative causes include neuromuscular and inflammation. Iatrogenic/Intoxication causes include neuro toxins and toxins causing inflammatory lesion. Congenital causes include joint deformity and pressure lesion. Autoimmune causes include immune mediated hypersensitivity. Traumatic causes include previous unknown trauma causing pressure lesion, repetitive stress due to strain or instability. Endocrine/Metabolic causes include cushings, hypothyroidism and diabetes mellitus. Myofascial causes include restrictive tissue, referred pain, nerve entrapment and lick granuloma.
Definitive Diagnoses: 1) Bilateral carpal hyperextension (left worse): degenerative joint disease seen on radiographs, possibly due to inflammation, repetitive stress due to strain and instability, restrictive tissue, referred pain or nerve entrapment. Less likely diagnoses include vasculitis, sepsis, rickettsial, bacterial, osteomyelitis, fungal neoplasia (metastatic, lymphoma, paraneoplastic), neuro toxin, joint deformity, congenital tendinopathy, immune mediated arthropathy, joint luxation/ subluxation, neuromuscular disease, cushings, hypothyroidism, malnutrition and diabetes mellitus. This list is unlikely to resolve and then recur or the signs would progressively worsen despite therapy. 2)Recurring wound on left ventral carpal pad: lick granuloma or pressure lesion as a result of the degenerative joint disease seen on radiographs, possibly due to inflammation, repetitive stress due to strain and instability, restrictive tissue, referred pain or nerve entrapment. Less likely diagnoses include vasculitis, sepsis, insect bite, rickettsial, bacterial, osteomyelitis, fungal neoplasia (metastatic, lymphoma, paraneoplastic), neuro toxin, joint deformity, congenital tendinopathy, immune mediated arthropathy, joint luxation/ subluxation, neuromuscular disease, cushings, hypothyroidism, malnutrition and diabetes mellitus. This list is unlikely to resolve and then recur or the signs would progressively worsen despite therapy.
Medical Decision Making: Patient had been receiving twice weekly laser treatments (arthritis settings) to both carpi and left shoulder with minimal results seen for 6 treatments. Laser treatments are an effective focal area therapy for decreasing inflammation and increasing blood supply. We added in acupuncture to target a larger area of myofascial tissue restriction (including caudal cervical spine, cranial thoracic spine/ dorsal scapular and distal humerus) and bring in neuromodulatory effects (decrease sympathetic tone, increase parasympathetic effects and improve circulation). A specific goal was to neuromodulate sensory to the carpus and that the autonomics would tone down sympathetic hyperactivation and decrease patient urge to lick the wound area. The treatments were performed once to twice a week for 2 and ½ weeks. Medical Acupuncture and Related Techniques Used: Point selection- Dry needling for 20 minutes at BL 13, BL 14, BL 15, BL 27, BL 60, LI 4, LI 11, GV 14, GV 20, ST 36, LU 7, LR3. The treatments were once to twice a week for 2 and 1/2 weeks. Laser treatments were continued and administered after the acupuncture treatments. Point selection rational- BL 13, BL 14 and BL 15 for myofascial restrictions of dorsal scapular region and neuromodulation of this area to reduce wind up from nociceptive afferent bombarding spinal cord (cranial thoracic spinal nerves) and local pain BL 13, BL 14 (local pain and anxiety), BL 15 (local pain and anxiety). BL 27 for connective tissue associations along this channel along with BL 60. LI 4 for sensory to carpus (mechanoreceptors and nociceptors), foot and distal antebrachium (radial nerve and nervi vasorum in carpal arterial arch to bring in nutrients to heal wound), autonomic fibers (sympathetic regulation-wind up) and circulatory effects. LI 4 also causes caudal cervical spinal nerve stimulation (C5-C8/T1, covering the entire brachial plexus) also paresthesia or pain from the neck (myofascial restriction- nerve entrapment). LI 11- extensor trigger point- he was very sensitive to this point, this could also be from possible referred pain (caudal cervical spinal nerve roots). LI 11 also has immune modulation and anti-inflammatory effects (wound healing) and decreases sympathetic tone along with LI 4, GV 14 and ST 36. The Large Intestine channel runs along this patient’s line of dysfunction (shoulder myofascial restriction leading to nerve entrapment along the channel). ST 36 (parasympathetic), GV20 for anxiety and parasympathomimetic (sending somatic to trigeminal nerve and upper cervical, cross talk with vagus nerve) and LR 3 (good for anxiety). LU 7 for skin disorders and carpal pain (connects with LI 4). The acupuncture needles used were 0.20 x 25mm, Millennia and were left in place for 20 minutes. The Class IV Companion laser (810nm) arthritis settings of total 660 J delivered continuous mode at 8 W to each carpus and to the left shoulder.
Outcomes, Insights, Discussions: Chronic medial shoulder instability can lead to a persistent forelimb lameness. This instability may lead to abnormal compensation potentially causing additional disease. This case study has enlightened my understanding of treating the patient as a whole in contrast to focusing directly on focal pathology. The treatment of the patient’s myofascial restrictions, trigger points and modulating the autonomic nervous system has shown beneficial to his overall wellbeing. It is unlikely that the acupuncture treatments have brought stability to his hyperextended carpi but the chronic recurring wound has improved. The owner describes him as being “lively” and less tearing off bandage. We will continue adding acupuncture treatments to his laser therapy sessions to see if we can further stabilize this disease. Ultimately, surgical repair or long-term bracing may be necessary for this patient. The ability to provide comfort and support to the rest of his body is a continuous goal.
References: McKee M Diagnosis and management of chronic joint pain in the dog In Practice 2013;35:227-242. Scott H, Witte P Investigation of lameness in dogs In Practice 2011;33:20-27. Harasen G. Arthrodesis–Part I: The carpus. Can Vet J. 2002;43(8):641-3.