Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4L2018061
Abstract
‘Sun and Fun’, a 17 year old Warmblood Stallion, that competes in Grand Prix level Dressage. The client/rider says his performance has lacked impulsion through the hind end and that his back had been sore. Myofascial examination and joint mobilization revealed pain bilaterally over the caudal lumbar spine, lumbosacral joint and caudal epaxial muscles. Treatments were targeted mainly toward this area involving Bai Hui and caudal Bladder line points. Throughout the treatment course, involving three sessions, the pain response over caudal lumbar spine, lumbosacral joint and caudal epaxial muscles significantly improved. The client noted the stallion’s overall performance and impulsion through the hind end also notably improved.
History and Presentation
‘Sun and Fun’ is a 17 year old Brown Warmblood Stallion used for mainly for Grand Prix level dressage and stallion duties over Spring/Summer. He has a history of intermittent lameness (left front – LF) and has been diagnosed with a LF suspensory tear (approx. 3 years ago) prior to purchase by his current owner. He is kept in a small yard and will occasionally get swelling in his left front leg if not wearing a boot or given phenylbutazone. The client is mostly concerned about his back and reports he has intermittent soreness and reluctance when placing the saddle or during palpation. The client is the main/sole rider and a certified professional has fit the saddle used on Sun and Fun.
First treatment: 17/7/18
The day prior to his first physical examination and treatment, Sun and Fun completed two strenuous Grand Prix level dressage tests for training purposes. The client/rider reported he was slightly lazy, showed a mild pain response when palpating along his back and lacked some impulsion from behind. The client/rider observed no lameness yesterday however the horse did receive 15ml PO of Phenylbutazone 200mg/ml 30 mins before the test (approx. 22 hours prior to today’s examination).
Physical Exam and Clinical Assessments – First Treatment
• Visual assessment: Good BCS 5.5/9
o Swelling LF proximal to fetlock and thickening over sesamoids.
o Swelling over dorsal aspect of left hind (LH) hock through suspected tendon sheath.
o Note: Client did not want to pursue further diagnostics to work up these abnormalities, as he believes it is not of clinical significance.
o Symmetrical musculature
• Clinical Parameters – all within normal limits
• Balance: LF slow, LH slow, right front (RF) normal, right hind (RH) normal
• Myofascial exam
o Tight/tense over left and right gluteals
o Tight/tense over left and right caudal lumbar spine
• Joint mobilisation
o Dental points (TMJ) reactive unilaterally both sides and bilaterally
o Neck flexion to the left and right – negative
o Gator – slightly reluctant with right limb extended cranially
o Left front limb
Scapula extended back – slightly reluctant
Adduction of carpus out slightly reluctant
Slightly painful over palpation of the suspensory on LF
o Right front limb – same exam performed as for LF limb, no abnormalities detected (NAD)
o Left hind limb – NAD not painful on palpation of swelling noticed over hock
o Right hind limb – NAD not painful on palpation
o Back flick – negative
o Back tuck – positive response over caudal lumbar spine
o Fishtail – slightly positive over caudal lumbar spine both sides
o BL 27 press (SI joint) – negative both sides
o Lumbosacral (LS) press – positive both sides
o Leg spins/circles – negative bilateral
• Trot up on straight line and lunged both direction – no evidence of lameness detected
• Full limb flexion test – negative all 4 limbs
• No neurological deficits noted
Problem List
• Swelling over LF flexor tendons
• Thickening over LF sesamoids
• Swelling over LH hock
• TMJ pain response
• Tight myofascial palpation over left and right caudal lumbar spine and gluteals
• Back tuck and fishtail – positive over caudal lumbar spine bilateral
• LS press – positive bilateral
Diagnosis
• It was difficult to obtain a definitive diagnosis due to restrictions on diagnostics available and permitted by client. I recommended imaging (radiograph) of the caudal lumbar spine however the client declined. Based on clinical exam findings the bilateral pain over caudal lumbosacral region may be musculature or have bone/joint in nature.
• Muscle soreness over the gluteals may be strain or partial tear or due to fatigue from exercise prior to today’s examination
• Possible oral/TMJ pain requires further examination under sedation with dental gag, offered to work this up however client declined.
Differential Diagnosis
• Thoracolumbar/caudal lumbar pain
o Muscle soreness/primary muscle spasm
o Osteoarthritis of synovial articulation
o Intervertebral disk disease
o Combination of lesions within thoracolumbar and lumbosacral regions
o Sacroiliac injury
• Gluteal pain
o Muscle injury
o Muscle fatigue/exertion from previous exercise
o Muscle tear
– For thoracolumbar, caudal lumbar and gluteal pain:
V – Vascular: Local vasculitis, cellulitis
I – Infection: Bacterial meningitis,
N – Neoplastic: Soft tissue sarcoma, meningioma, rhabdomyosarcoma
D – Degenerative: Osteoarthritis, nutritional muscular dystrophy (WMD)
I – Iatrogenic/intoxication: Poor saddle fitting/poor rider positioning, organophosphate myositis, pasture associated myositis
C – Congenital: Synostosis, kyphosis, lordosis
A – Autoimmune: Immune mediated myositis, equine motor neuron disease
T – Traumatic: Poor saddle fitting/poor rider positioning, paddock accidents
E – Endocrine/Metabolic: Polysaccharide storage myopathy
Medical Decision Making
The main concern for the client and myself was addressing the soreness over the back and hind muscles in particular bilateral epaxial muscles and gluteals. I recommended baseline ultrasound of superficial/suspensory tendons, dental examination for assessment of possible oral pain and imaging of caudal lumbar spine however the client declined for the present time. The three acupuncture treatments were spaced over approximately 3 weeks. The neuromodulation approach was targeting the fascia and musculature over caudal lumbar spine and gluteal area
Acupuncture Treatments
Session 1: Bilateral treatment where possible (all but GV 14 and Bai Hui)
All needles used for each treatment were No. 5 0.25 diameter 30mm Seiren coated
• GB 21, LI 14 as initial calming/neck twitch points and are repeated for the remaining treatments for the same reasoning.
• GV 14: indicated for back pain
• Bai Hui: indicated for lumbosacral pain
• BL 21: tender to palpation
• BL 23: indicated for lumbar pain and local pain
• BL 25: indicated for lumbosacral pain
• BL 26: indicated for lumbar pain
• BL 27: indicated for sacral pain
• BL 54: indicated for gluteal pain
Electroacupuncture, laser and other adjunct therapies were not available for this patient during the course of the treatment.
2nd Treatment: 27/7/2018
History
Client reports ‘Sun and Fun’ has been doing well since last treatment, no soundness issues detected, moving better, no issues during riding with back or hind end. The plan is for him to be in light work now until November/December when breeding season starts. Swelling in the LF limb present today however has not been out of small yard for four days. Swelling over the hock is less defined today. No treatment with Phenylbutazone since last treatment.
Physical Exam and Clinical Assessments – Second Treatment
• Clinical Parameters – all within normal limits
• Balance: Normal
• Myofascial exam
o Dental points (TMJ) reactive unilaterally both sides and bilaterally
o Tight/tense over left and right gluteals
o Tight/tense over right caudal lumbar spine
• Joint mobilisation
o Neck flexion – NAD both sides fine scapula fine all directions LHS,
o Front limbs: right scapula protraction positive, remaining NAD
o Back flick – positive right caudal lumbar
o Back tuck – positive left and right caudal lumbar
o Withers walk – negative
o Fishtail – to the left negative and to the right positive over caudal lumbar spine
o LS Squeeze – negative
o Leg spins – NAD
• No evidence of lameness at the trot on the straight or on a circle both directions
Acupuncture Treatments (2nd Session)
• GB 21, LI 16
• GV14
• Bai Hui
• BL 23, BL 25, BL 27, BL 54
• Right shoulder:
o BL 11: indicated for local tension/pain restriction of scapula elevation
o BL 12: indicated for local trigger points/ local pain
o BL 13: local trigger points/pain restriction of scapula elevation
o LI 15: indicated for local trigger points with myofascial restriction, Neuromodulation of suprascapular nerve
o TH 14: indicated for local tension or pain points, Neuromodulation of suprascapular nerve
3rd Treatment: 10/7/18
History:
‘Sun and Fun’ was lunged and had a light work session yesterday; client reported no evidence of lameness or any issues with performance. He reports the horse seems happier overall, no pain on palpation of back or when placing saddle and was more willing to engage hindquarters. No treatment with Phenylbutazone since last treatment.
Physical Exam and Clinical Assessments – Third Treatment
• Swelling over hock reduced
• Swelling over left front tendons reduced
• Clinical Parameters – all within normal limits
• Balance – normal
• Less myofascial restriction however still slightly tense over right caudal lumbar spine
• Less resistance to palpation of gluteals (bilaterally)
• Right shoulder minimal resistance to scapula protraction
• Moving better at the trot up, appears more free, action looking improved on last week
3rd Treatment Points
• GB 21, LI 16, GV14
• Bai Hui
• BL 25, BL 26, BL 27
• Indications as previously stated
Outcomes
• The pain response over caudal lumbar spine notably decreased
• The client reported the stallion had more impulsion through the hind, the horse was also more willing to engage hindquarters when asked.
• No intermittent left front lameness since starting sessions (this may be coincidental as no targeted treatment toward that area). This may be the same for the swelling in the hindlimb over hock that reduced throughout the course of the treatments.
• I have recommended imaging (radiographs) of caudal lumbar spine depending on progress with acupuncture treatments or possible referral of Equine Surgeon (specialist referral centre).
• This case has allowed me to visualize the benefits and results of acupuncture for muscle related pathology/presentations. Targeting neuromodulation of the underlying fascia and musculature has resulted in a significant improvement in this stallion’s performance.
• There were no adverse effects noted throughout the duration of or after the treatments.
References
• Ross, M & Dyson, Sue. (2011). Diagnosis and management of lameness in the horse. 10.1016/C2009-0-50774-X.
• Curacore Clinical Intensive Notes
• Curacore Equine Point Manual