Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018060
ABSTRACT: Mud Bud is a 7 month old mixed breed dog. He fractured his femur at 3 months of age. He did well after surgical repair but developed a grade 3 medially luxating patella on the same limb. His owner wished to avoid more surgery and opted to try physical therapy and agreed to add acupuncture. Mud Bud tolerated acupuncture very well for a young, active dog. After 4 acupuncture treatments over 4 weeks, and 12 weeks of physical therapy, Mud Bud improved clinically and the owner no longer appreciates patellar luxation.
HISTORY AND PRESENTATION:
Mud Bud is a male mixed breed dog born 11/22/2017. Mud Bud fractured his right femur (mid diaphysis) February 2018 at 3 months of age and was surrendered. It was repaired surgically he was adopted by the roommate of a hospital employee. The fracture has healed, but currently Mud Bud has grade 3 right medial patellar luxation. The owner reports occasional lameness at home, sometimes after playing. She can feel the patella luxating in and out. Mud Bud has had no other known trauma and is otherwise healthy.
PHYSICAL EXAM AND CLINICAL ASSESSMENT:
June 23, 2018 – First evaluation: On physical exam there was no noticeable lameness, but Mud Bud was only observed walking inside. Right proximal hind limb muscle atrophy was present and medial patellar luxation was noted on the right. The muscles of the head palpated normal. Abnormal muscles included taut bands in mid-ventral neck muscles and both pectorals were taut. There were taut bands in muscles cranial to humerus, and mildly taut muscles caudal to humerus, right worse than left. Along the spine, palpation was normal in the thoracic region but there was some tenderness and tightness of the mid to caudal lumbar muscles bilaterally. In the right hind limb, there were tight muscles cranial and caudal to femur and decreased skin motion of right hind femoral area and right caudal lumbar area. I did not get to fully evaluate the left hind limb as Mud Bud seemed to want to be on his left side as I was trying to palpate and I wanted to make the first visit as non-stressful as possible. Therefore, I focused palpation on his back and right hind limb.
Initial exam assessment: Mud Bud had right hind limb atrophy and proximal hind limb musculature tightness. This could be due to a combination of disuse secondary to femur fracture and healing after repair, as well as current patellar luxation. The lumbar muscular tension and forelimb/pectoral tension were likely related to altered weight bearing.
Other additional information: Fracture was healed and well aligned radiographically. Bloodwork was normal at time of surgery.
DIFFERENTIAL DIAGNOSES:
1. Right medial luxating patella
2. Right hind muscle atrophy secondary to femur fracture and post-operative recovery
3. Right hind muscle atrophy secondary to luxating patella
4. Altered mechanics secondary to trauma and post-operative recovery
5. Altered weight bearing from other soft tissue injury
DEFINITIVE DIAGNOSES:
1. Grade 3 right medial luxating patella – diagnosed by CSU orthopedic service; appreciated on physical exam
2. Healed right femur fracture – surgery and follow up at CSU
3. Right hind muscle atrophy – historical and on physical exam
MEDICAL DECISION MAKING:
Overall, the main goals for Mud Bud were to relieve muscle tension, activate atrophied muscles, and aid in strengthening quadriceps muscles that could help maintain normal patellar alignment. I also used acupuncture points that could address stifle pain and dysfunction.
For the first visit for an active puppy, I decided to start with just a few needles. I started the treatment with palpation and massage, which relaxed Mud Bud. For acupuncture points, I started with GV 20 to aid in relaxation, which did seem to help. Second, I placed Bai Hui for pelvic limb pain and dysfunction. I then tried to address areas of tension and attempted to activate muscles that were atrophied and muscles that would help correct medially luxating patella. Over the course of 4 treatments, I added additional acupuncture points as Mud Bud became more tolerant.
MudBud video before acupuncture
ACUPUNCTURE TREATMENTS:
Four total treatments. I used all dry needling only with red Seirin 0.16mm diameter, 30 mm length needles. With each treatments, I tried to increase the number of points as Mud Bud got used to the process. For every treatment I started with a myofascial exam and massage, and ended with massage and skin rolling.
1ST TREATMENT JUNE 23:
Physical exam: Noted in clinical assessment above.
Mud Bud relaxed with massage and palpation and after placement of GV 20. Other needles placed included Bai Hui, lumbar spinal nerves right and left of L5, GB 34 and ST 36. Mud Bud tolerated the treatment very well. The needles were in for 20 minutes, although GB 34 and ST 36 were probably in closer to 5-10 minutes due to patient motion and sniffing.
The owners were surprised with how calm Mud Bud got and how well he tolerated the treatment. I started with just a few needles to begin with to try to make it a good experience. We did give frozen baby food near the end of the treatment because Mud Bud started getting a little restless. I finished with massage and skin rolling.
POINTS USED: GV 20, Bai Hui, GB 34, ST 36, and points of tension in lumbar muscles lateral to L5 bilaterally.
2nd TREATMENT JULY 2:
Assessment – owner said Mud Bud seemed to feel better/ do better after first treatment. Current assessment: no visible lameness while moving. Mud Bud did off-weight right hind leg (affected leg) when stopping and standing. When sitting, he extended the same leg while he used to tuck under more. There is still right hind muscle atrophy, generalized proximally.
On physical exam, there were tender points/ muscle tension/taut bands in lateral neck, left infraspinatus, and both hind limb quadriceps and hamstrings, left worse than right. There were not appreciable tight muscles in back, but the patient responded to palpation at T-L and in the caudal lumbar region. There was decreased skin movement right lumbar region and over scar on the lateral right proximal hind limb.
POINTS USED: GV 20, Bai Hui, points of tension in lumbar muscles lateral to L5 bilaterally, GB 30 on right, ST 36 bilaterally, GB 34 on right, ST 34 on right; SI 11 on left
After treatment, Mud Bud was more lame and shifting weight to left and the right patella was visibly luxating in and out. The owner did say he had rough housed with other dogs right before I came over, and he is often lame when he first gets up after playing then laying down. On palpation after treatment, there was less response to palpation of back.
3rd TREATMENT JULY 9:
Mud Bud still shifted weight off his right hind when still, but looked normal when moving and playing. There was a similar palpation pattern on physical exam. The right infraspinatus was taut, the neck had tight bands, and Mud Bud reacted to palpation of T-L and lumbar regions. In the right hind limb, the mid to caudal aspect of quadriceps were tight, the hamstrings were tight, and there is muscle atrophy. In the left hind, the cranial part of quadriceps was tight. There was improved but still decreased skin movement in area of scar and right lumbar region.
POINTS USED: GV 20, GV 14, Bai Hui, points of tension in lumbar muscles lateral to L5 bilaterally, ST 36 right, GB 34 right, ST 34 right, Right front leg ST 11, ventral lateral neck bilateral in taut muscles
There was noticeable trembling of both hind limbs during treatment but Mud Bud seemed relaxed. After treatment he seemed to be using his right hind limb a little better though still did off weight when still.
4th TREATMENT JULY 18:
The owner reported increased lameness past few days but Mud Bud has been very active. He held his right hind limb out more when sitting. There was mild lameness when walking and running. He was still shifting weight to the left but seems decreased compared to previous. On physical exam, the neck tension was still present but better and there were still taut bands infraspinatus bilaterally. The triceps were normal. There were taut bands cranial and caudal thigh bilaterally. There was not palpable tension in back but Mud Bud still responded to palpation at the T-L and lumbar regions. There was improved but still decreased skin movement in area of scar and in the right lumbar region. The owner did feel that overall Mud Bud is improving and that the patella is luxating less frequently, despite recent increase in lameness.
POINTS USED: GV 20, Bai Hui, points of tension in lumbar muscles lateral to L5 bilaterally, GV 14, GB 30 right, ST 36 right, ST 34 right, BL 54 and BL 60 right, LI 15 bilaterally, TH 14 bilaterally, SI 11 left
Mud Bud tolerated all treatments well.
RATIONALE FOR POINTS USED:
GV 20 – calming
GV 14 – neck and back pain
BaiHui – good for LS pain, pelvic limb pain or neurologic dysfunction
GB 30 – sciatic nerve – good for hip problems, sciatic nerve dysfunction/pain
GB 34 – fibular nerve – good for stifle pain, musculotendinous pain or tension, lateral pelvic limb or hip discomfort
ST 36 – fibular nerve – good for stifle pain and pelvic limb dysfunction
ST 34 – femoral nerve – good for stifle pain and instability and/or dysfunction, femoral nerve injury
LI 15 – treats shoulder joint pain and cervico-thoracic spinal roots
TH 14 – shoulder and local pain, caudal cervical spinal nerve roots
BL 54 – sciatic nerve dysfunction, hip or gluteal pain
BL 60 – sciatic or pelvic limb pain
MudBud video after acupuncture 2
OUTCOME: The combination of physical therapy and acupuncture allowed Mud Bud to improve enough that surgery is not currently warranted. His patella is rarely luxating at this point and he using both hind limbs more evenly according to the owner. Adverse events were: 1) Increased lameness after treatment, which owner attributed to rough-housing immediately before acupuncture, though acupuncture may have contributed and 2) trembling of leg during treatment which resolved on its own and did not recur. What I learned from the case is 1) a combination of physical therapy and acupuncture may be used as an alternate therapy to surgery in some cases of medial luxating patella, 2) Puppies can tolerate acupuncture surprisingly well, 3) Small adverse reactions or outcomes (such as increased lameness immediately after treatment or leg trembling during treatment) do not require a panic response, or an immediate shift in plan. I do not own a laser, but use of a laser in Mud Bud would have been a good complement to acupuncture in regions that were tender, hard to access for needling, or sites of early needle displacement due to patient motion.
Update February 2019: Mud Bud continues to do well with no current lameness and no patellar luxation noted by the owner.