Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 3D2019002
Abstract:
A dog was evaluated on April 11, 2019 for lameness of the right rear leg of two days duration. The dog’s owner had noticed the dog had difficulty turning on this leg as well. The dog was examined and an injury to the cranial cruciate ligament of the right stifle was suspected. Acupuncture using dry needling was performed for four treatments. Gradual improvement was noticed although treatment continues as needed.
History:
Daisy is a well-muscled, 8-year old, spayed female, mixed-breed dog. On April 11, 2019, she presented to our clinic for lameness of the right rear leg of two days duration. She has a previous history of intermittent back pain and had been treated with dry needling acupuncture to the bladder line. She had responded well to this protocol.
The owner knew of no recent trauma that preceded the observed lameness. The owner had noticed for the two days prior a reluctance to jump up and difficulty turning on the right rear leg. The owner had been giving Daisy carprofen 35.5mg by mouth every 24 hours as needed for pain.
Routine blood work including a complete blood count and serum chemistry were performed March 7, 2019 with no significant findings. A complete urinalysis was performed April 7, 2018 and results were all within normal limits. Daisy receives Heartgard Plus monthly for heartworm prevention and Bravecto every ninety days for flea and tick protection. She has had no other medical issues since owners rescued her approximately 2 years ago.
Physical Examination Findings:
Upon presentation Daisy was ambulatory but mildly lame on the right rear. Her lameness was graded a II/IV. On physical exam, she was approximately five pounds overweight. The remainder of her general physical exam was unremarkable. Her myofascial exam found taut bands over her right hip area. She had mild tension over the lumbar back muscles and both her quadriceps and hamstring muscles of the right rear leg were mildly tender to light palpation. The remainder of her myofascial exam was unremarkable. She was found to have mild cranial drawer to the right stifle and had mild periarticular effusion to the right stifle. She was mildly reactive over the mid-lumbar to caudal-lumbar area as well.
Problem List:
• lame right rear, grade II/IV
• positive cranial drawer right stifle, mild
• periarticular effusion right stifle, mild
• mid- to cranial-lumbar tension, mild
• tenderness to the right quadriceps and hamstring muscles
• overweight approximately five pounds
Differential diagnoses:
Lameness, right rear:
Vascular: vascular hamartoma; Legg-Perthes Disease; thrombus
Infectious: abscessation; Lyme disease; bacterial meningitis, onychomycosis; diskospondylitis; Neospora myositis; septic arthritis
Neoplastic: osteosarcoma; osteochondroma; spinal tumor
Degenerative: osteoarthritis; degenerative myelopathy; intervertebral disk disease
Iatrogenic/Intoxication: complications from previous surgical treatment, post-vaccinal polyradiculoneuritis; overuse injury secondary to obesity
Congenital: hip dysplasia; transitional vertebrae; onychodystrophy;
Autoimmune: immune-mediated polyarthritis; polyradiculoneuritis; acquired myasthenia gravis
Traumatic: joint sprain/strain; hit-by-car; fracture; onycholysis; Achilles tendon rupture, cranial cruciate injury
Endocrine/Metabolic: metabolic neuropathy due to metabolic diseases such as diabetes mellitus or hypothyroidism
Myofascia: muscle strain/sprain, polymyositis; iliopsoas myopathy
Instability right stifle (positive cranial drawer), periarticular effusion:
Vascular: thrombus
Infectious: Lyme disease; septic arthritis
Neoplastic: synovial chondromatosis; osteosarcoma
Degenerative: degenerative joint disease stifle
Iatrogenic/Intoxication: previous joint injection; failure of previous cranial cruciate repair
Congenital: conformational problem
Autoimmune: immune-mediated polyarthritis
Traumatic: cranial cruciate injury; collateral ligament injury
Endocrine/Metabolic: cranial cruciate ligament rupture secondary to hyperadrenocorticism or hypothyroidism
Myofascia: injury to hamstring muscles
Putative/Differential Diagnoses:
The differential diagnoses for Daisy’s lameness were narrowed to include cranial cruciate ligament injury with secondary myofascial strain based on her physical exam findings and pattern of myofascial tenderness. It is believed to be secondary to either traumatic injury or overuse injury based on her history of previous intermittent back pain. Causes such as intervertebral disk disease or degenerative joint disease cannot be ruled out without radiologic study. Other differential diagnoses listed were excluded based on history and exam findings.
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 21 were both utilized for autonomic nervous system effects. Acupuncture sessions were immediately followed by 5-10 minutes of gentle massage to the back and both hips and thighs to encourage myofascial release.
Table 1: Treatment Date 4/11/2109
Point used Duration Needle size (Brand)
Bai Hui 15 mins .20x30mm (Seirin)
BL 26 left & right 15 mins .20x30mm (Seirin)
BL 27 left & right 15 mins .20x30mm (Seirin)
GB 29 right 10 mins .16x30mm (Seirin)
GB 30 right 10 mins .16x30mm (Seirin)
GB 31 right 10 mins .16x30mm (Seirin)
BL 54 right 10 mins .16x30mm (Seirin)
ST 34 right 10 mins .16x30mm (Seirin)
ST 36 right 15 mins .16x30mm (Seirin)
LR 10 right 8 mins .16x30mm (Seirin)
Table 2: Treatment Date 4/19/2019
Point used Duration Needle size
Bai Hui 12 mins 0.20x40mm (Hwato)
GV 21 10 mins 0.20x30mm (Seirin)
BL 26 left and right 12 mins 0.20x40mm (Hwato)
BL 27 left and right 12 mins 0.20x40mm (Hwato)
ST 34 right 8 mins 0.20x30mm (Seirin)
ST 36 right 8 mins 0.20x30mm (Seirin)
lateral stifle area 5 mins 0.20x30mm (Seirin)
mid-thigh taut band 8 mins 0.20x40mm (Hwato)
Table 3: Treatment Date 4/27/19
Point used Duration Needle size
Bai Hui 15 mins 0.20x30mm (Seirin)
BL 23 left and right 15 mins 0.20x30mm (Seirin)
BL 25 left and right 15 mins 0.20x30mm (Seirin)
ST 34 right 15 mins 0.20x30mm (Seirin)
ST 36 right 15 mins 0.20x30mm (Seirin)
Daisy has gradually improved from continuous lameness to the right rear to intermittent lameness with intervals of abnormal range of motion becoming increasingly less frequent. She will continue to receive treatment as needed. The owner reported perceived improvement to her range of motion following each treatment performed.
Discussion:
Cranial cruciate disease is commonly diagnosed in dogs. Whether the injury is acute or chronic, the stifle is predisposed to degenerative changes as a result of the instability associated with this disease (1) and these changes will continue to affect range of motion in the affected limb even if surgery correction is pursued (2). If acupuncture can keep the pet ambulating at a more normal gait, perhaps muscle atrophy and other long-term consequences can be avoided while the owner consider surgical versus medical management of cranial cruciate disease.
References:
(1) Agnello KA, Holsworth IG, Caceres AV, Cimino-Brown D, Runge JJ, Schlicksup M, Hayashi K. Articular cartilage lesions of the patellofemoral joint in dogs with naturally occurring cranial cruciate ligament disease. Vet Surg. March 2014;43(3):308-15.
(2) Mölsä SH, Hyytiäinen HK, Hielm-Björkman AK, Laitinen-Vapaavuori OM. Long-term functional outcome after surgical repair of cranial cruciate ligament disease in dogs. BMC Vet Res. November 2014;10(0):266.
General References:
Adrega Da Silva C, Bernard F, Bardet JF, Théau V, Krimer PM. Fibrotic myopathy of the iliopsoas muscle in a dog. Vet Comp Orthop Traumatol. 2009;22(3):238-42.
Damur-Djuric D, Steffen F, Hässig M, Morgan JP, Flückiger MA. Lumbosacral transitional vertebrae in dogs: classification, prevalence, and association with sacroiliac morphology. Vet Radiol Ultrasound. 2006 Jan-Feb;47(1):32-38.
Fritz C, Kjemtrup A. Lyme borreliosis. J Am Vet Med Assoc. 2003; 223(9): 1261-70.
Jaffe M, Kerwin SC, Fitch RB. Canine Diskospondylitis. Compend Contin Educ Vet. 1997 ;19(5):551-555
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.