Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4L2019012
Abstract
Severe, acute onset hindlimb lameness in a 15-year-old mare, which responded only moderately to conservative treatment, was isolated to primarily right sided middle gluteal, longissimus, lumbosacral and sacroiliac inflammation. Three treatments of veterinary medical acupuncture at weekly intervals yielded a resolution of muscular and myofascial pain, improved gait, and eliminated lameness returning the mare to her previous athletic function.
History and Presentation
A 15-year-old warmblood mare school horse presented for acute lameness of unknown origin in the hindlimbs one week prior. She had been rested one week and was markedly improved by the time of presentation according to the trainer. Initial presentation found the mare to be lame bilaterally behind 2/5 right hind (RH) and 1/5 left hind (LH) (AAEP lameness scale). LH displayed limited upper limb range of motion (ROM) and moderate medial femorotibial (MFT) effusion. RH she exhibited severe pain to deep palpation of the entire middle gluteal, and had a fasiculation response to superficial palpation of BL27 and BL31. Biceps femoris proximally and the caudal sacroiliac (SI) region displayed marked pain to superficial myofascial palpation as well as decreased upper limb range of motion. Classical lameness exam was pursued and the clinically relevant findings were a moderate to marked positive stifle flexion (tibial retraction and elevation) on the RH and a moderate positive response on the LH. RH limb adduction yielded a mild-moderate response. The most notable finding was that pressure to BL27, BL31 and muscle distal to it on the right via the gluteal caused a marked positive response and change in gait (4/5 positive flexion), with a reduced stride length and increased loading on the opposing limb. Mild pressure at BL27 for a full 30 second test prior to jogging off could not be endured. Lower limb regional analgesia and nuclear scintigraphy were declined based on findings and cost. The pelvis, hip and stifles will subsequently ultrasounded for gross abnormalities identifying enlargement and chronic change noted in both the left (L) and right (R) medial menisci and mineralization (moderate) of the LS disk, but no fracture, hematoma or visible musculotendinous abnormalities were identified. Complete blood count and biochemistry performed supported a muscular trauma diagnosis with an elevated creatine kinase 349 IU/L (range 37-184 IU/L).
Based on the work up; initial differential was muscular and myofascial trauma to the R middle gluteal and longissimus aponeurosis with a secondary differential diagnosis of acute LS and SI inflammation with possible compression and nerve entrapment. Conservative treatment was elected based on cost, including stall rest, hand walking and flunixin at 250 mg once daily (0.55 mg/kg). Progress exams at 8 days post presentation and 16 days post presentation showed consistent improvement. Flunixin was discontinued at 8 days, and tack walking was initiated at 16 days as the lameness had decreased to 0.5/5 RH and the LH lameness had resolved. Gluteal sensitivity had improved and considered to be mild sensitivity to deep palpation but continued to have a fasiculation response to palpation. Work was gradually increased and over a 3 week span the mare moved from walking to trot and then canter for increasing time under tack. 3 weeks later, the mare continued to have a subtle lameness RH and gluteal pain.
Physical exam and clinical assessment
Temperature, pulse, respiration thoracic and gastrointestinal auscultation, mucous membranes, eyes, ears, lymph nodes, oral exam and integument were all unremarkable. The mare was bright, alert responsive. Neurologic assessment revealed normal behaviour and mentation, cranial nerve function, proprioception and segmental reflexes
Myofascial exam: Slight myofascial restriction over the bracheocephalicus at C4-6 – R and L, and over trapezius – R and L. Mild to moderate myofascial restriction R and L semimembranosus/semitendinosus. Moderate myofascial restriction over thoracic longissimus (R was marginally more restricted than L) and L lumbar longissimus. Moderate to marked myofascial restriction of the L superficial and middle gluteal. Marked myofascial restriction R lumbar longissimus, superficial and middle gluteal. A very slight fasiculation response at BL27 and 31 persists on deeper palpation.
Musculoskeletal exam and passive flexion and palpation: For brevity, only significant clinical findings are discussed. Normal limb placement at rest, the mare is in good body condition (scored 5/9) and in reasonable muscling with no overt hypertrophy or atrophy. Normal digital pulses in all four feet.
Internal rotation of shoulder yields a mild discomfort response bilaterally. Mild reduction in dorsal scapular elevation bilaterally. Moderate effusion of the LH MFT joint, mild effusion of the RH MFT joint. R and L hock range of motion (flexion) mildly reduced. Upper limb abduction is mildly reduced on the L and moderately reduced on the R. Tibial retraction on the R elicited a slight to mild pain response. Hindlimb circumduction displays reduced range of motion, and the mare fails to relax in the movement and will not extend the hind limbs (R-moderate, L–mild). The mare displays resistance to forelimb protraction with cervical mobilization bilaterally. Cervical lateral bending is reduced mildly bilaterally, with somewhat more difficulty to the L. Cervical articular facet mobilization was mildly reduced from C4-C7. Wither mobilization was mildly restricted. Thoracic dorsoflexion was moderately reduced, lumbar dorsoflexion was guarded. Tuber sacrale compression, LS and sacral slide mobilizations were not performed based on the mare’s myofascial exam and discomfort indicating significant underlying pain in this region. Lumbosacral lateral flexion was guarded, as was pelvic ventroflexion. Trigger point sensitivity in caudal trapezius, longissimus at the level thoracolumbar (TL) and lumbar levels, longissimus-gluteal aponeurosis, and in the gluteal at the LS and SI level along the bladder line. Lameness score is 1/5 RH.
Problem list
1) RH lameness with pelvic, upper limb and thoracolumbar pain and myofascial disease
2) LH pelvic and thoracolumbar pain and myofascial disease
3) Cervical restriction (C4-6) with myofascial pain restriction
Differential diagnoses (using the VINDICATE THE MYOFASCIA acronym)
Vascular – hematoma, compartment syndrome. Infectious/Inflammatory – LS, sacral or sciatic neuropathy, equine protozoal myloencephalitis, myositis. Neoplastic – bone neoplasia of the lumbosacral region or dorsal abdominal tumour. Degenerative – SI joint disease, LS disk disease; hip, stifle and hock arthritis, lumbar overriding dorsal spinous processes. Secondarily, caudal cervical facet arthritis, distal forelimb lameness. Iatrogenic/intoxication and congenital – none based history. Autoimmune – anaplasma myositis (very unlikely based on presentation). Trauma – undiagnosed pelvic, lumbar or sacral fracture, primary gluteal tear, iliopsoas tear. Endocrine – none based on history. Myofascia – myofascial disease of the longissimus, longissimus-gluteal aponeurosis, gluteals and biceps femoris.
Putative diagnosis
Gluteal myopathy with possible aggravation of lumbosacral disk and sacroiliac joint disease, and associated longissimus myofascial dysfunction. Based on local trigger points sciatic nerve dysfunction or inflammation is suspected
Medical decision making
Assessment of historical exam findings and diagnostics, along with current physical, lameness and myofascial exams suggest that the primary area of focus is the thoracolumbar longissimus, the LS and SI junctions, the superficial, middle and deep gluteals, and biceps femoris musculature as well as associated fascia and nervous tissue. Though a definitive diagnosis has not been isolated, the clinical symptomology indicates inflammation (and possible re-injury) of the LS junction (possible re-aggravation of the mineralised LS disk), SI joint and muscular trauma and myofascial disease of the middle gluteal and surrounding musculature, as well as with possible nerve pain. The muscle enzyme findings in previous exam along with the initial severe sensitivity to myofascial and muscular palpation support a diagnosis of primary muscular trauma. Cervical range of motion and brachiocephalicus tension suggest a secondary focus for treatment, however based on this horses’ sensitivity to acupuncture, the focus for point selection and area of treatment was chosen to prioritize treatment as the LS/SI/Gluteal region. Therapeutic focus was chosen as thoracolumbar, lumbar and sacral spinal nerves, sciatic, caudal gluteal, tibial and fibular.
GB21 was chosen as an initial access point and for TL, spinal and accessory nerve (nn) function. BL 13,21,23,25 and 27 were chosen based on trigger point sensitivity and longissimus function. BL13 functions via the midthoracic spinal nn and is useful for pain in trapezius, rhomboideus, serratus, erector spinae, splenius. BL21 and 23 both act on the TL spinal nn. While BL21 is the stomach Shu point and this was considered, these points were chosen for their ability to aid in potential nerve entrapment and treatment of local tender points in longissimus, latissimus, erector spinae, quadratus lumborum and BL25, specifically the thoracolumbar fascia.
BL25, 27 and Bau Hui were chosen for their spinal nerve function as well as their propensity to treat lumbosacral and sacral pain. The middle gluteal is expansive in the horse and has a large fascial aponeurosis with the longissimus; BL23, 25 and 27 were selected to treat myofascial restriction in that area. BL25 is supplied but the mid-lumbar spinal nn and targets lumbosacral pain along with erector spinae, longissimus, thoracolumbar fascia. BL27 is supplied by S1 spinal nn and aids in sacral pain and local tender points within the thoracolumbar facia. Bai Hui is supplied by mid to caudal lumbar spinal nn and is helpful with back and lumbosacral pain, pelvic limb pain and neurologic dysfunction, but is also notable for its neuromodulatory effects. BL 54. GB 29 and 30 were selected based on their muscular positioning as well as nerve function. BL54 is supplied by cranial gluteal nn and the dorsal ramii of sacral spinal nn. GB29 is supplied by the caudal gluteal n, sacral spinal nn, and GB30 is supplied by the sciatic n and caudal gluteal n. Collectively they treat the gluteal fascia, superficial, middle and possibly deep gluteal, tensor fascia latae, lateral hip muscles, biceps femoris and quadriceps femoris. ST 36 is a fibular nerve point, which was chosen for neuromodulation and support of higher sciatic targeting. It offers afferent input to the nucleus tractus solitarius and dorsal motor nucleus of the vagus nerve allowing for its overall parasympathetic effect. BL 40 is a tibial nerve point and was chosen as a distal reinforcing sciatic point as well as for the treatment of local trigger points of the semimembranosus, semitendinosus, gastrocnemius.
Treatment and Techniques
GB21, BL13,21,23, BL25,27, Bai Hui, BL40,54, GB29,30 ST36 were chosen to treat with 0.30 x 0.40 Seirin. This protocol was performed at 7-day intervals for 3 consecutive weeks. Electroacupuncture was applied from BL27 to BL54 bilaterally. This was only tolerable for 10 mins at 20-23 hz on the first treatment, but became more tolerable and treatment 2 and 3 consistent of 20 mins EAP. A change in needle diameter had been considered after the first treatment due to patient sensitivity, however with improvement in relaxation and comfort in the mare, and the nature of the anatomy and problem, patient, slow needle placement and maintenance of the larger diameter needle was chosen.
Outcome/Discussion
Over the 3 weeks of therapy, the patient improved from persistent discomfort in the longissimus and gluteal musculature with decreased lumbar and pelvic ventroflexion and a fasiculation response on palpation of BL27/31 to marked improvement in myofascial restriction and sensitivity. By the end of the third treatment the following improvements are noted: R tibial retraction no longer elicits pain, longissimus discomfort was reduced to very slight, lumbosacral lateral flexion and pelvic ventroflexion were able to be performed and yielded no pain response. The mare gained the ability comfortably to perform hindlimb circumduction and was able to extend the limb. Thoracic and lumbar dorsoflexion improved and were no longer guarded. Tuber sacrale compression, LS and sacral slide mobilizations were able to be performed and were considered to have only mild discomfort. Myofascial sensitivity and restriction had improved significantly enough on the right to yield similar responses to the left. RH lameness resolved, and cranial and caudal phase of stride were elongated. Muscular, myofascial and mobilization related pain all improved drastically with this treatment. Based on the response to therapy, it is concluded that dry needling and electroacupuncture yielded excellent results to treating presumptive gluteal myopathy, longissimus myofascial dysfunction with possible aggravation of lumbosacral disk and sacroiliac joint disease. These findings also suggest that primary myofascial disease can be a cause of lameness, and should be considered when treating athletes. While the author believes therapeutic laser and massage may have had additional significant benefit to this case, without their addition, the physical improvement in this mares’ comfort over the treatment period was drastic, and indicative of the strength of medical acupuncture as a treatment modality for muscle, lumbosacral and sacroiliac pain as a source of lameness in horses.
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