Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018038
Abstract
Gidget is a twelve-year-old quarter horse mare with a history of intermittent lameness and chronic back and neck soreness. The owner would like to make Gidget comfortable enough to do light arena riding and light trail rides for another several years if possible.
After five acupuncture treatments over the course of three months, Gidget’s lameness has improved and her stride at the walk and trot appears to be significantly less restricted. I was able to diagnose underlying osteoarthritis in the cervical facets from C4-C6 which is likely a large contributing factor to her discomfort and will be addressed in the near future.
History and Presentation
“Gidget” is a twelve-year-old quarter horse mare with a history of navicular disease (2014), coffin joint osteoarthritis (2014), tarsal arthritis (2015), sacroiliac pain (2015), carpal arthritis (2017) and generalized back pain (2016) after being ridden. She has always been very “ear shy” and in the summertime a black, waxy substance can be appreciated within the external ear canal. Until age 9, Gidget was used as a competitive cutting horse and she has had at least one foal. Intra-articular injection of corticosteroids and hyaluronic acid (Hyvisc, HA) is performed at regular intervals to treat the osteoarthritis. Osphos (bisphosphanate) is given IM to help slow osteoclastic activity related to progressive navicular disease. Gidget receives Adequan annually every spring.
She presented for treatment due to a worsening right front lameness under saddle and generalized body soreness. The owner reports she has become resistant to lateral bending under saddle and feels “stiff as a board”. Gidget is used as a ranch horse for cattle work, ranch roping, and mountain trail riding. The owner would like to make Gidget comfortable enough to do light arena riding and light trail rides for another several years if possible.
Physical Examination & Clinical Assessments
Myofascial Palpation Evaluation:
Gidget appears to be over at the knee conformationally (right worse than left). She is also very upright in her shoulders as well as her front pasterns. Lameness evaluation reveals 1/5 (AAEP grading scale) RF lameness, strongly positive to flextion of R carpus. Hind limb full limb flexion strongly positive bilaterally. On palpation, ST7 and the temporomandibular joint are sore bilaterally, with a more marked reaction on the left side. BL10 is very reactive to light palpation and the rectus capitus ventralis muscle belly palpates very tight bilaterally. Ventral cervical flexion is within normal limits; however lateral cervical flexion on C2-C4 is absent both to the right and to the left. There is a tight band of muscle tissue within the belly of the cervical portion of the serratus ventralis which is also tender to palpation on the left side. Her brachiocephalicus muscle appears to be over-developed and gives her a “ewe-necked” appearance. The supraspinatus and infraspinatus muscle bellies are reactive to palpation bilaterally, and there is decreased internal rotation of the left elbow and shoulder. Myofascial restriction is also present in the long head of the triceps muscle on the left side. The right carpus exhibits decreased range of motion, particularly flexion and internal/external rotation of the distal limb.
Gidget is highly reactive to palpation of the longissimus dorsi and spinalis muscle groups from approximately T8 to the L/S junction on both sides of the spine. She has a trigger point on BL 54 bilaterally and is tender to SI palpation. She exhibits decreased range of motion of the thoracolumbar spine bilaterally but is able to flex the lumbar spine relatively comfortably. She has decreased range of motion and discomfort in the sacroiliac joints when performing both clockwise and counter-clockwise rotation of both hind limbs. Decreased range of motion in left front and right front coffin joints.
Initially, ventral flexion of the cervical spine (including protraction of the forelimb) was significantly decreased bilaterally and she resisted. When attempted again a second and third time after lateral bending of the cervical spine was tested, Gidget was able to reach much farther ventrally.
Neurologic Examination:
Cranial nerves & reflexes are within normal limits. Conscious proprioception of forelimbs and hind limbs is within normal limits. The walking tail pull is slightly weaker to the right side than the left, which may be due to right front lameness rather than neurologic disease. Gidget exhibits pain when asked to walk with her head elevated, but no neurologic symptoms were noted. When walking over ground poles, the right front limb consistently taps the pole. When asked to back in a straight line, she takes three to four good steps before beginning to circumduct her hind limbs and raise her head, presumably due to lack of fitness and discomfort.
Brief description of imaging findings:
Osteoarthritic changes are present in the left and right front coffin joints, navicular bone changes are present in both front feet, osteoarthritic changes present in both hocks (tarsal metatarsal and distal intertarsal joints), and osteoarthritis of the right carpus.
Imaging of the cervical spine was performed, and there is osteoarthritis of the cervical facets at C4-C5 C5-C6.
Problem List
• Decreased range of motion of the right front carpus, bilateral front coffin joints, and bilateral hock joints
• Myofascial restriction and pain of the muscles over both shoulders, and thoracolumbar spine.
• Myofascial restriction and pain of cervical spine, as well as decreased range of lateral motion
• Navicular disease (based on radiographic changes and known history)
Differential Diagnoses for Top Two Problems
1. Right forelimb lameness
a. Carpal osteoarthritis
b. Navicular disease
c. Coffin joint osteoarthritis
2. Thoracolumbar myofascial restriction and pain
a. Kissing spinous processes
b. Soft tissue strain of spinal ligament
c. Muscular strain and imbalance due to compensation for pain in other areas of the body
Vascular-during the winter months when temperatures are cold, blood is shunted away from peripheral vasculature towards the abdominal and thoracic cavities, decreasing the many benefits of blood flow to the joint capsule such as healing, flexibility of soft tissue structures including the joint capsule, and increasing pain and stiffness.
Infectious- although highly unlikely in this case, an infection such as EPM (equine protozoal myeloencephalopathy) can cause gait asymmetry lameness, and muscular atrophy.
Neoplastic- neoplasia of the musculoskeletal system is very rare in horses
Degenerative- this is most likely caused by degenerative changes from osteoclasts associated with progressive oseoarthritis
Iatrogenic- poor saddle fit, living on hilly terrain
Congenital- EPSSM (equine polysaccharide storage myopathy) and HYPP in horses can cause episodes of tying up, which when mild may present like generalized stiffness and body soreness.
Autoimmune- immune-mediated myositis, causing intermittent muscle atrophy and pain. This, while a possibility, does not seem likely due to the chronic and specific nature of Gidget’s pain.
Traumatic- being ridden hard on mountainous terrain most likely contributed to the accelerated progression of osteoarthritis as well as other adaptive and compensatory changes within the muskuloskeletal system.
Endocrine/Metabolic: various tying up syndromes such as RER (recurrent equine rhabdomyolysis) can present as generalized stiffness and bodysoreness before progressing to muscle fasciculations.
Definitive (or Putative/assumed) Diagnosis (or Diagnoses)
Osteoarthritis of the right carpus, bilateral hock joints, bilateral front coffin joints, and navicular disease. Musculoskeletal restriction and pain on the thoracolumbar spine.
Medical Decision Making
At this point in Gidget’s career, it would be most beneficial to focus on preventative and palliative care. Osteoarthritic changes are not reversible, but the resulting inflammation and pain has a significant impact on the way that Gidget moves and her day to day comfort level and quality of life. We can help her by addressing these issues with a MAIN (Medical Acupuncture and Integrative Neuromodulation) as well as administering chondroprotective pharmaceuticals such as Adequan and Osphos (bisphosphonate), as well as a daily selective COX-2 non-steroidal medication (such as firocoxib). Gidget would also benefit from daily stretching and strengthening exercises to increase strength and range of motion in joints themselves as well as the supporting musculature. Saddle fit, although not the cause of her thoracolumbar pain, is an important factor in maintaining comfort while riding.
Medical Acupuncture and Related Techniques Used
First treatment Dry needling: ST7, BL10, LI18, GB21, LI17, LI16, BL54, BaiHui. Massage of outer bladder line, and osteopathic manipulation of Cervical and lumbar spine.
Second treatment Dry needling: ST7, BL10, Bl13, 14, 15. LI18, GB 21, LI17, LI16, BL 54, BaiHui.
Third treatment dry needling: ST7, BL10, Bl13, 14, 15. SI11, SI12. BL 21, 23, 25, 27. LI18, GB 21, LI17, LI16, BL 54, BaiHui
Fourth treatment: Dry needling at BL10, LI18, GB21, LI17, LI16, BL54, BaiHui, SI 11, SI12. BL 21–>BL23, BL25–>BL27 electroacupuncture across outer bladder line to specifically treat thoracolumbar pain.
Fifth treatment: Dry needling at BL10, LI18, GB21, LI17, LI16, BL54, BaiHui, SI 11, SI12.
Outcomes, Discussions, and References
After five integrative treatments, Gidget appears to move more comfortably and works on lateral bending under saddle without great resistance. Due to prevalent and progressive degenerative joint disease and significant osteoarthritis, it is imperative that Gidget continue regular treatments to support her musculoskeletal system and address areas of myofascial restriction, imbalance and pain. Patients with advanced degenerative joint disease benefit from consistent, light to moderate exercise which should be monitored carefully by a veterinarian. She would also benefit from rehabilitation exercises to increase core strength, distal limb proprioception, and lateral flexion. I recommend that she continue to receive the same preventative treatments she has been on: daily Prevacox, Adequan, Osphos, and intra-articular corticosteroids and hyaluronic acid as needed (up to twice yearly).
References:
Xie H, Colahan P, OHEA. Evaluation of electroacupuncture treatment of horses with signs of chronic thoracolumbar pain. Journal of the American Veterinary Medical Association. 2005 Jul 15; 227 (2): 281-6.
Smith, Mary O. Neurological Examination for the Busy Practitioner. AAHA Press, 2002. Lakewood, CO.
Supporting media
IMG_2297.jpg shows cervical spine range of motion exercises and osteopathic manipulation
IMG_2306.jpg shows trigger point release within the cervical spine with dry needling
IMG_2312.jpg shows dry needling treatment within the hind end
IMG_2286.mov shows improved trot (after treatment) on the straightaway
IMG_2288.mov shows improved gait on circle to the left
IMG_2290.mov shows improved gait on circle to the right, however the right front lameness is still present