Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10L2018038
Abstract:
Shorty’s Metal, a six-year-old Quarter Horse mare used for cutting competitions, was diagnosed with proximal suspensory desmitis in the right hind. Improvement was noted in her lameness grade and ultrasonographic findings with only three weeks of in-hospital focused rehabilitation. Integrative and rehabilitative therapies utilized included platelet rich plasma, shockwave, therapeutic ultrasound, laser, acupuncture, massage, and chiropractic. Shorty’s Metal is expected to make a full recovery and return to her previous level of competition.
History and Presentation:
Shorty’s Metal, a six-year-old Quarter Horse mare used for cutting competitions, presented with a right hind end lameness of five days duration following a performance. Physical exam vital parameters were within normal limits. Lameness evaluation revealed a grade 3 out of 5 right hind lameness according to the grading scale established by the American Association of Equine Practitioners. The lameness was exacerbated when trotted with the right hind to the outside of a circle. On observation of her confirmation, she was noted to have straight angles in her hocks bilaterally. Neurologic assessment showed no abnormalities with the patient being able to adequately resist a tail pull, back-up normally, and obtain proper feet placement when circumducted. No areas of muscle atrophy were appreciated. An abaxial nerve block of the right hind actually exacerbated the lameness. Improvement in stride length and fetlock drop was finally observed following a tibial nerve block.
Problems List and Differentials:
With consideration of a right hind lameness worse to the outside of a circle, the patient’s blocking pattern, and undesirable confirmation, the top two differentials were proximal suspensory desmitis or a lesion in the associated soft tissue structures such as the superficial digital flexor, deep digital flexor, or check ligament.
Medical Decision Making and Diagnosis:
On ultrasound examination of the proximal right hind metatarsus, an enthesophyte on the caudal aspect of the cannon bone, compression of the metatarsal vasculature surrounding the suspensory ligament, and an irregular hypoechoic region within the suspensory ligament was noted. Such evidence indicated that proximal suspensory desmitis was the major contributor to Shorty’s Metal’s discomfort. With the collaboration of findings, the owner elected to leave Shorty’s Metal in-hospital for two weeks of rehabilitation therapy following immediate treatment with intralesional platelet rich plasma and shockwave therapy. Initial rehabilitation assessments/treatments were to include myofascial massage, chiropractic palpation/manipulation, and acupuncture.
Rehabilitation Assessment, Protocols, and Outcome:
Myofascial findings revealed trigger points in the right side latissimus dorsi muscle, right side trapezius muscle, right side serratus ventralis muscle, left side transversus abdominus muscle, caudal lumbar epaxial muscles, and gluteal muscles bilaterally. Adhesions were palpable in the left triceps brachii muscle. Mild atrophy was noted in the right triceps brachii muscle. Myofascial restriction and course texture were appreciated throughout the brachiocephalicus muscles bilaterally.
Chiropractic palpation techniques revealed excellent balance when picking up all four feet. Both front limbs showed adequate range of motion along with adduction and abduction of the carpus and lower limb joints while flexed. Shorty’s Metal ventroflexed well, being able to reach down to both front canon bones and in between her legs; however, behavior did not allow for sustainment of the flexion. No pain was elicited upon palpation of the withers. When stimulating the epaxial muscles, good dorsal and ventral movement was noted until reaching the lumbar region which lacked mobility. Both hind limbs exhibited restricted movement when circling in both directions. Mild discomfort was noted on manipulation of the left sacroiliac joint. The lumbar vertebrae were restricted in lateral bending but improvement was seen more cranially in the thoracic region. The cervical vertebrae showed no pain to palpation yet lateral bending was mildly restricted bilaterally.
During the first acupuncture treatment, 0.25X40mm purple Seirin needles were placed at LI 16 bilaterally, Bai Hui, BL 25 bilaterally, BL 27 bilaterally, BL 54 on the left side, GB 29 on the left side, and GB 30 on the left side. Shorty’s Metal began to buck across the barn following placement at BL 54 which resulted in cessation of needling. She was resistant to any further needle manipulation. Once she stood quietly, the needles were left for 20 minutes prior to removal.
Another acupuncture treatment was conducted four days later with vast improvement in patient attitude. The same points were utilized as previously mentioned in addition to being able to achieve placement at BL 54, GB 29, and GB 30 on the right side. Trigger points were found throughout the brachiocephalicus and longissimus dorsi muscles bilaterally during myofascial examination in which needles were also placed locally.
A third acupuncture treatment took place one week later with the same points. Unfortunately, Shorty’s Metal was once again resistant but tolerable to placement of needles in the right hip region. Myofascial progression was appreciated with a decrease in the amount of palpable trigger points and adhesions with improvements in mobility of the cervical region.
Throughout the two-week duration of her stay, an automatic Assissi Loop was placed in the region of the proximal right hind suspensory to deliver targeted pulsed electromagnetic therapy. Therapeutic ultrasound set to a ligament specific setting was used four times, with evenly distributed treatments. Shockwave therapy was repeated prior to Shorty’s Metal’s discharge from the clinic. Stall confinement was advised at this time for at home instructions.
Shorty’s Metal returned in one week for a recheck and an additional week of rehabilitation. Lameness evaluation revealed improvement from a grade 3 to a grade 2. She responded well to another acupuncture treatment; however, points on the right hip were avoided due to previous discomfort in order to create a more relaxing session. At that time, trigger points were found in the left triceps brachii muscle that were addressed. Throughout the duration of her week stay she received laser therapy daily with a MR4 ActiVet laser at level 4 on red. Shockwave therapy was repeated to fulfill a regular treatment regimen. Ultrasonographic recheck showed a less prominent enthesophyte, improvement in vascular compression, and an evident change in the fiber pattern of the suspensory ligament resulting in less hypoechogenicity, At the time of discharge, it was advised to continue stall confinement with added-in controlled exercise consisting of hand walking for 5 minutes twice daily.
Conclusion:
Overall, the combination of rehabilitation protocols assisted in improvement in the integrity of the proximal right hind suspensory ligament. Shorty’s Metal was much more comfortable from a musculoskeletal standpoint after targeting the areas affected due to compensatory mechanisms that developed. The end goal is to slowly increase her work load in order to have her ready for elite competition in 2020. We are currently waiting on an additional follow up appointment in order to further advance her rehabilitation program that will make that goal possible.