Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2018056
Abstract:
This case report is about Lily, a 5 year old spayed female mixed breed dog with a partial cranial cruciate ligament (CCL) tear of the left hind (LH) stifle and compensatory pain in the forelimbs. This was diagnosed at the first acupuncture session- prior to this her owners just noticed an intermittent multi-limb lameness. Her owners did not want to pursue further diagnostics at that time. Lily showed improvement after the first two treatments because her activity was restricted according to Dr. Barrett’s recommendation. However, the morning of the third treatment she jumped out of the car and became acutely three-legged lame on the left hind limb. Her last acupuncture treatment was performed and she was subsequently evaluated by a veterinarian and diagnosed with a complete tear of the CCL. Her owners are currently pursuing surgical treatment.
History and presentation:
The patient, Lily, is a 5 year old spayed female mixed breed dog. She presented for a chronic intermittent multiple limb lameness of both forelimbs and the left hind limb. Her owners noticed the lameness about 6 months ago and believed it was getting worse. The owners typically exercised her vigorously as she has a lot of energy, and their normal activities included walking, running, hiking, playing at the dog park and playing fetch with a ball. Her lameness was usually worst the day or two after vigorous exercise, especially in the mornings as she became stiff overnight. Her owners said the footing at the park was uneven which possibly contributed to higher impact on joints. Since noticing the lameness her owners stated they have decreased running with Lily but she had not been evaluated by a veterinarian since, and they were reluctant to try conventional therapies such as NSAIDs for pain. She iss also slightly overweight and is fed 1.5 cups per day of Science Diet Bioactive commercial food plus many treats. She was suspected to have discoid lupus erythematosus about 2 years ago by her previous veterinarian based on clinical signs alone including ulceration of the nasal planum. The owner declined further diagnostics including biopsy. They have tried to avoid excessive UV light to help with her nose but it still appeared mildly ulcerated and erythematous. Her only surgical history is her sterilization when she was 6 months old. She has past history of dog attacks and as a result has become dog aggressive. Her owners have spent time with a dog trainer to try to work on her behavioral issues. Current medications were Heartgard and Nexgard given monthly.
Physical examination and clinical assessments:
Findings on physical exam were as follows. Body condition score was 6/9. The patient was ambulatory on all four limbs. Muscle hypertonicity was found through the infraspinatus, supraspinatus and triceps muscles bilaterally. Trigger points were found in the left latissimus dorsi muscle. All joints of the forelimbs showed normal range of motion. There was no reaction to spinal palpation. The left stifle was painful on hyperextension and during cranial drawer and tibial thrust manipulations. These manipulations also revealed moderate instability of the left stifle. Mild effusion was palpated within the left stifle. The right hind limb was normal. The patient had no obvious neurologic deficits. The nasal planum was mildly erythematous and ulcerated. The rest of her physical exam was within normal limits.
Differential diagnoses:
Differential diagnoses for left stifle pain included CCL degenerative disease, stifle osteoarthritis, CCL tear, meniscal tear, and patellar tendonitis.
Definitive (or putative) Diagnoses:
Based on the physical examination, working diagnoses were partial tear of the cranial cruciate ligament of the left hind stifle, with secondary compensatory pain in the forelimb soft tissue bilaterally. In this case the owner was not able to do anything more than acupuncture. They were not willing to do further diagnostics initially for the stifle to confirm CCL tear radiographically, or a sedated orthopedic exam to check for instability without causing pain and distress to the patient. However, based on the positive sit test, painful hyperextension of the stifle, history of left hindlimb lameness, and palpable effusion, the initial working diagnosis was a partial tear of the CCL. Radiographs of the hips, forelimbs and spine would have been helpful to identify arthritis, mineralized discs, or other abnormalities.
Medical decision making:
The approach to the acupuncture protocol considered points to neuromodulate centrally, peripherally, locally, and autonomically.
Hind limbs-
-central : points between L4 and S2 (BL 25, 27, 28) to interrupt nociceptive pathways to the spinal cord
-peripheral : sciatic nerve points (BL 36, 54), femoral nerve point (GB31) to improve limb proprioception
-local stifle points (ST 34, 36; SP 9, 10) for controlling pain and inflammation and increase local circulation
-autonomic points (Bai hui, ST 36) for immunomodulation and anxiety reduction
Fore limbs-
-central: points between C4 and T2 (BL11) to interrupt nociceptive pathways to the spinal cord
-peripheral: radial nerve points (LI11) to improve limb proprioception
-local points (SI9) for tricep trigger points
-autonomic points (GV 14, LI 11) for immunomodulation and anxiety reduction
Although there were many points that could have been beneficial for Lily, she only tolerated short sessions with several needles so I did not use all of the points discussed in my plan. She would sometimes try to bite so I avoided points near her front end because the owner was holding so I did not feel completely safe to needle in that area.
Medical Acupuncture and Related Techniques:
Treatment 1 (1/26/19): Bai hui, GV 14, Left ST36, Left ST34, Left GB 31; Bilateral: BL 25, BL27, BL28.
Treatment 2 (2/11/19): Bai hui, GV 14, Left ST36, Left ST34, Left GB 31; Bilateral: BL 25, BL27, BL28.
Treatment 3 (2/24/19): Bai hui, GV 14, Left ST36, Left ST34, Left GB 31; Bilateral: BL 25, BL27, BL28.
These acupoints were treated at each point with a filiform stainless-steel needle (AP needle Seirin brand, 0.16x30mm). The angle of needle insertion was 10 to 20 degrees, with horizontal insertion. During the treatment, the needling stimulation and manipulation consisted of simple insertion without lifting, thrusting, twirling, or rotating. The needles were retained for 5 min.
Outcomes, discussion, references:
After the first treatment the patient’s lameness improved. The owners listened to the recommendations for a suspect partial tear to make exercise more controlled, on leash only and mild activity only. They were able to use less Rimadyl which they felt positively about because they do not like giving western drugs if possible. They also started administering Cosequin and CBD daily. Weight loss was recommended by decreasing caloric intake, since physical activity also needed to be decreased.
Between the second and third treatments, Lily jumped out of the car and became acutely non-weight bearing on the left hind limb and very painful. The injury happened the morning of the third treatment, so that is why the “after” video shows her as three-legged lame. She was subsequently evaluated by a veterinarian who diagnosed a complete tear of the CCL. The owners had a surgery consult which included radiographs and are saving up for her TPLO surgery.
Curacore Integrative Medicine and Education Center. “Medical Acupuncture for Veterinarians Canine Point Mini-Manual”.
Schwartz, Cheryl. “Four Paws, Five Directions”.
What I learned from this case:
This was a very interesting case for my report. It was satisfying to give the owners a working diagnosis initially because they had no idea what was wrong with her. I wish her owners could have kept her more restricted so that she didn’t injure herself more, especially during the course of the case report. I was grateful to have given her some pain relief the day she injured herself worse. I am glad that her owners finally pursued diagnostics and treatment in the end, although it may have been more helpful if they had done it earlier on in the course of her disease.
I also learned how valuable it is to have trained staff holding during acupuncture for certain patients. We did Lily’s acupuncture at her home with her owners holding and I think we were able to do less needles than we could have with her restrained a bit more. A few times she tried to swing around and nip at me because she was nervous. She was difficult to work with sometimes and we had to be creative to find ways to calm her down and get her to relax. In the end it worked out well to feed her sweet potato salad during her treatment to distract her, as that is a favorite snack of hers. I think I gained some of her trust by working with her patiently and gently as well.