Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 3D2019002
Abstract:
A horse was evaluated on April 28, 2019 for chronic lameness of the left front leg. Dry needling acupuncture was begun to try to improve mobility for Ty. He has received several treatments to date and has responded favorably. Treatment is ongoing.
History:
Ty is a 22-year old, gelded male, American Paint Horse. The owner has noticed bony changes to the left hock for several years. Ty receives 1 gram of phenylbutazone by mouth twice daily and receives Cosequin once daily. He has been on these medications for approximately three years. He is dewormed routinely and receives annual vaccinations. He had juvenile arthritis to both hocks when he was approximately six years of age which was treated at that time. He is currently pastured on grass and has a shelter in his pasture. The owner desires for Ty to be as pain-free as possible in his senior years; he is retired from riding and all other work.
Physical Examination Findings:
Upon initial physical exam, Ty is bright, alert, and responsive. He is ambulating with difficulty; lameness to the left front is graded 4/5 using the lameness scale designated by the American Association of Equine Practitioners (AAEP). He has bony swelling to the left carpus and suffers from carpus varus of the left carpus. Both hocks appear stiff upon ambulation and manipulation but he does not seem to resent examination of the hocks. He is very reluctant to lift either front foot. Myofascial exam reveals ‘ropiness’ to both cranial shoulder areas and he has trigger points in both cranial shoulder areas consistent with GB21 and LI16. He has taut bands in both triceps areas as well. No radiologic exams have been done.
Problem List:
Lameness left front 4/5
Bony swelling left carpus
Carpus varus left carpus
Muscle tenderness to both shoulders and both triceps
Decreased range of motion, both hocks
Differential diagnoses:
Lameness, left front:
Vascular: vascular hamartoma; vasculitis; laminitis; ischemia; thrombus
Infectious: hoof abscessation; septic arthritis; cellulitis; myelitis; tetanus; Lyme disease; equine protozoal myeloencephalitis (EPM); rabies; West Nile virus
Neoplastic: spinal tumor; brain tumor
Degenerative: osteoarthritis; intervertebral disk disease; cervical vertebral stenotic myopathy (Wobbler disease)
Iatrogenic/Intoxication: poorly trimmed or shod feet; improper pasture substrate
Congenital: overuse injury due to poor conformation; osteochondritis dissecans (OCD); hyperkalemic periodic paralysis; polysaccharide storage myopathy
Autoimmune: immune-mediated polyarthritis; polyradiculoneuritis; equine fibromyalgia syndrome
Traumatic: joint sprain/strain; fracture; muscle sprain/strain; shoulder “sweeny” (atrophy to the supraspinatus and infraspinatus muscles due to trauma to suprascapular nerve); proximal suspensory ligament desmitis; navicular bursitis
Endocrine/Metabolic: hyperkalemic periodic paralysis; polysaccharide storage myopathy; exertional rhabdomyolysis; Cushing’s disease
Myofascia: muscle strain/sprain, polymyositis;
Swelling left carpus:
Vascular: edema (“stocking up”)
Infectious: septic arthritis; tenosynovitis
Neoplastic: osteochondroma
Degenerative: degenerative joint disease; osteoarthritis
Iatrogenic/Intoxication: complications from previous joint injection; carpal hygroma due to bedding issues
Congenital: conformational problem; angular limb deformities
Autoimmune: immune-mediated polyarthritis
Traumatic: fracture; osteochondral fragmentation; proximal suspensory ligament desmitis; carpal bursitis; exostoses (“splints”)
Endocrine/Metabolic: Cushing’s disease; equine metabolic syndrome
Myofascia: muscle strain/sprain
Putative/Differential Diagnoses:
The differential diagnoses for Ty’s lameness were narrowed to include osteoarthritis to the carpal joint with secondary myofascial strain to his shoulders, neck and triceps muscles based on his history, signalment, physical exam findings and pattern of myofascial tenderness.
Treatment Approach:
Three sessions of dry needling acupuncture were utilized as therapy. Acupuncture points were selected based on myofascial exam findings. Master points and traditional channel points with known effects upon the stifle were also selected. Bai Hui and GV 14 were both utilized for autonomic nervous system effects. Seirin brand needles, size no. 3 (0.20) x 40mm and size no. 8 (0.30) x 30mm were utilized. Treatment duration ranged between five to fifteen minutes per treatment each day depending on Ty’s cooperation and needle grab.
Table 1: Treatment Date 4/28/2109
Point used
Bai Hui
GV 14
BL 11, right and left
BL 12, right and left
BL 13, right and left
BL 43, left
SI 14, right
TH 15, left
GB 21, right and left
SI 9, left
Triceps trigger point x 1, left
Table 2: Treatment Date 5/4/2019
Point used
Bai Hui
GV 14
BL 11, right and left
BL 12, right and left
BL 13, right and left
BL 43, left
GB 21, left
LI 15, left
SI 10, left
SI 11, left
LI 10, left
TH 5, left
LI 6, left
taut bands to the mid-cervical neck x 2, left
trigger point to the left triceps x 1
Table 3: Treatment Date 5/13/19
Point used
Bai Hui
GV 14
BL 11, left and right
BL 12, left and right
GB 21, left and right
SI 11, left
LI 10, left
trigger points to the left triceps muscle, x 1
trigger points to the right triceps muscle, x 2
Ty had small improvement following treatment on 4/28/19 and 5/4/19. However he became significantly more lame on 5/10/19. Re-evaluation on 5/13/19 found additional trigger points to both triceps muscles. His owner reported significant improvement was noticed two days following the third treatment. His treatment will continue as needed.
Discussion:
Osteoarthritis of the carpus joint in horses is a common issue, especially in Arabian and in Quarter horses. It is characterized by progressive lameness and can develop marked bony changes to the carpal joint. It more commonly affects the medial aspect of the carpometacarpal joint. With chronicity it can progress to development of joint capsule thickening and decreasing range of motion of the carpal joint.
Treatment can involve work restriction, intra-articular anti-inflammatory injections, systemic anti-inflammatory medications, and, in advanced cases, arthrodesis of the joint. In older horses in which surgical treatment is undesirable or not feasible, alternative modalities of treatment should be considered. Underwater treadmill exercise is being evaluated for treatment as an adjunct to traditional treatment (1). Extracorporeal shock has shown some promise as an adjunct treatment as well (2). Acupuncture can be an additional treatment to provide palliative therapy for this condition. Acupuncture has been shown to also encourage cartilage repair in humans (3,4). Laser therapy and electroacupuncture would also be beneficial if available.
References:
(1) King MR, Haussler KK, Kawcak CE, McIlwraith CW, Reiser RF, Frisbie DD, Werpy NW. Biomechanical and histologic evaluation of the effects of underwater treadmill exercise on horses with experimentally induced osteoarthritis of the middle carpal joint. Am J Vet Res. May 2017;78(5):558-569.
(2) Frisbie DD, Kawcak CE, McIlwraith CW. Evaluation of the effect of extracorporeal shock wave treatment on experimentally induced osteoarthritis in middle carpal joints of horses. Am J Vet Res. April 2009;70(4):449-54.
(3) Zhang Y, Bao F, Wang Y, Wu Z. Influence of acupuncture in treatment of knee osteoarthritis and cartilage repairing. Am J Transl Res. January 2016;8(9):3995-4002.
(4) Cao L, Zhang X, Gao Y, Jiang Y. Needle acupuncture for osteoarthritis of the knee. A systematic review and updated meta-analysis. Saudi Med J. May 2012;33(5):526-32.
General References:
Finno CJ, Spier SJ, Valberg SJ. Equine diseases caused by known genetic mutations. Vet J. March 2009;179(3):336-47.
Fritz C, Kjemtrup A. Lyme borreliosis. J Am Vet Med Assoc. 2003; 223(9): 1261-70.
Malone ED, Les CM, Turner TA. Severe carpometacarpal osteoarthritis in older Arabian horses. Vet Surg. 2003 May-Jun;32(3):191-5
McCue ME, Geor RJ, Schultz N. Equine metabolic syndrome: a complex disease influenced by genetics and the environment. J Equine Vet Sci. May 2015;35(5):367–375.
Moody JL, Parks G, Herthel DJ. Hyperkalemic Periodic Paralysis: The Syndrome. Equine Pract. 1995 ;17(6):15-18.
Morley S, Traub-Dargatz J, Saville W, Wagner B, Garber L, Hillberg-Seitzinger A. Equine Protozoal Myeloencephalitis. J Equine Vet Sci. June 2001;21(6):262-270.
Read AJ, Finlaison DS, Gu X, Hick PM, Moloney BJ, Wright T, Kirkland PD. Clinical and epidemiological features of West Nile virus equine encephalitis in New South Wales, Australia, 2011. Aust Vet J. May 2019;97(5):133-143.
Ridgway K. Acupuncture as a treatment modality for back problems. Vet Clin North Am Equine Pract. April 1999;15(1):211-21.
Robinson NG. 2016. Interactive Medical Acupunture Anatomy. Jackson, Wyoming: Teton New Media.
Xie, H, Preast V. 2007. Xie’s Veterinary Acupuncture. Ames, Iowa: Blackwell Publishing.
Yasuno K, Kobayashi R, Ohmuro T, Kamiie J, Sahara H, Shirota K. Caudal vascular hamartoma accompanied by abherrant arteriovenous structures in a dog. J Vet Diag Investigation 2011; 23(5): 1051-1055.