Sam Receiving Medical Acupuncture
by Melinda Himler, DVM, cVMA, January 20, 2021
Abstract: Sam was diagnosed with a likely cranial cruciate tear based on a positive drawer sign and thickening of the stifle joint. Sam was initially started on twice-weekly acupuncture and then decreased to once weekly. Throughout the course of treatment, Sam began bearing weight on the limb and eventually walked without limping. However, she did still favor the limb on occasion.
History: Sam is a 10-year-old, female spayed Australian Shepherd mix that presented for non-weight bearing lameness in the left hind leg for two weeks. The owner reported that she was running and then yelped. The injury had not improved over the two-week course prior to presentation. Sam is an indoor dog, but is able to go outside and run. Sam has been a relatively healthy dog and has had no major illnesses or injuries previously. She did have a mild pyoderma over her trunk at presentation.
Physical Exam and Clinical Assessment: On examination, Sam presented with a 3/4 left hind lameness. Sam had positive cranial drawer in the left stifle and crepitus. There was also thickening of the stifle and myofascial restriction of the vastus lateralis and biceps femoris proximal to the stifle. Sam also had myofascial restriction in the triceps brachii and in the sternocephalicus and brachiocephalicus. She also had inflammation in the trapezius. Radiographs of the LH stifle and hips were within normal limits with the exception of the patella being slightly misplaced cranially. Sam’s neurologic exam showed no abnormalities. She had positive proprioception in all four feet and had a normal response to hopping. Sam also showed no ataxia and had a positive patellar reflex bilaterally.
Problem List: Problem list for Sam include left hind limb lameness, positive left hind cranial drawer, crepitus in left hind stifle, thickening of the left hind stifle, inflammation of the trapezius and myofascial restriction of the vastus lateralis, biceps femoris, triceps brachii, sternocephalicus, and brachiocephalicus.
Differential Diagnosis: Differential diagnosis for the 3/4 left hind limb lameness include Hemarthrosis, Lyme Disease, Osteosarcoma, Degenerative Joint Disease, Trauma from owner playing with dog, Congenital Bone Malformation, Systemic Lupus Erythematosus, injury while running (CCL tear, meniscal tear, collateral ligament tear), Cushing’s Disease due to loss of muscle mass and myofascial pain from any of the above conditions.
Differential diagnosis for thickening of the LH stifle include Vascular Hematoma, Septic Joint, Osteosarcoma, Degenerative Joint Disease, Joint Injections, Congenital Bone Malformation, Immune Mediated Polyarthritis, Cranial Cruciate Rupture, Hypothyroidism, myofascial pain due to any of the above conditions.
Definitive Diagnosis: Differential diagnosis was narrowed down to a likely cranial cruciate ligament tear for both of Sam’s top two problems. The positive cranial drawer sign was supportive of this diagnosis. Osteosarcoma was ruled out based on no bony abnormalities on radiographs. A septic joint was not considered likely due to the joint not being painful or warm to the touch. Lyme disease, Systemic Lupus Erythematosus and Immune Mediated Polyarthitis were ruled out due to lack of systemic disease and the involvement of only one joint. Injury due to playing with owner and joint injections were ruled out when speaking with the owner about history. Cushing’s Disease and Hypothyroidism cannot be excluded due to lack of testing. However, they are considered unlikely to be the cause of lameness in this case due to lack of clinical signs.
Medical Acupuncture and Related Techniques: Treatment plan was geared toward neuromodulation of the sciatic, femoral, tibial and fibular nerves to help with pain relief and improve healing of the stifle. The sciatic nerve provides sensory and motor sensation to the stifle and was addressed by stimulating spinal nerves that originate from L4-S2. The femoral nerve supplies the quadriceps, which is the extensor of the stifle and was stimulated by placing needles as spinal nerves exit at L2, L3 and L4. The femoral nerve is also sensory to anteriomedial thigh. The tibial and fibular nerves were addressed to help support the crus. Areas of myofascial restriction and inflammation were also addressed to help ease recovery. Helping to address inflammation and restriction will help ease stress on the stifle by allowing the body to move more freely. For most treatments, the left hind limb was addressed, but every four treatments; the right side was addressed to help address trigger points from over compensation. Initially, Sam was treated twice weekly. After three weeks, she was decreased to weekly treatments as she was walking fairly well at this point, but was still showing mild lameness in the left hind. After eight weeks in treatment, Sam was decreased to treatment every two weeks.
Sam began treatment on November 11th. Her exam included myofascial restriction in the lateral neck, inflammation in the intrascapular region, thickening of the left stifle along with positive cranial drawer and crepitus, myofascial restriction in both triceps and in the semimembranosus, semitendinosus and sartorius. Sam was also toe touching on the left hind. I started treatment with Seirin J type 0.16mm x 30mm. The points I used were BL40 to address hind limb pain and the tibial nerve; GB31 to address hind limb pain along with the sciatic and femoral nerves; ST34 and 36 to address stifle pain and dysfunction and the femoral nerve on the left; GV 14 and 20 were used to address the myofascial restriction in the cervical area; BL13-15 was used for the inflammation in the intrascapular region, BL 23, BL25 and lumbar points in between were used as central points to address the spinal nerves that give rise to the femoral and sciatic nn. The myofascial restriction in the triceps was also stimulated using local points. GV20 was also used for the agitation benefit as Sam did not want to take food for the session and this point seemed to settle her down for the acupuncture. Photomodulation was also used using a K laser on the left stifle using 5.0W, 660J for 2 minutes and 12 seconds.
Sam completed eleven additional treatments at the time of this paper. Photomodulation was repeated at each treatment. It was performed on the left stifle, but was applied to the right stifle every four treatments when the opposite limb was addressed due to myofascial restriction of the quadriceps and hamstrings in the limb. Only one side was addressed in one sitting as Sam did best lying shifted to one side. After the first treatment, Seirin 0.20 x 30mm needles were used for the final eleven treatments. Points that were added in throughout treatment included BL 27 and BL 28 to address hindlimb pain and address the S1 and S2 spinal nn. BL 54, GB 29 and GB 30 were also used frequently to help support the hips during recovery and stimulate the sciatic nerve (GB 30 and BL 54). SP 9 and 10 were also used as long as Sam was in a position that permitted medial access. This was used to help with stifle pain and to stimulate tibial and femoral nn.
Discussion: Sam showed significant improvement over the course of treatment. While Sam showed small improvements early in treatment and the owner noted she was more comfortable at home, it was after five treatments that Sam’s lameness was showing significant improvement. At this time, Sam was placing full weight on the limb, but was still hopping with the limb every few steps. After seven treatments, Sam was rarely hopping on the leg and while she was still lame in the left hind, she was able to bear full weight on the limb while walking. After 12 treatments, Sam was still showing mild stiffness in the left hind, but was able to walk on the limb the limb without hopping and had a normal stride. Sam is still in treatment at the time of this paper, but the frequency was decreased to every two weeks.
During treatment, Sam was maintained on carprofen twice daily for the first two weeks then decreased to once daily. After four weeks, Sam was taken off the carprofen and the owners were instructed to only give the carprofen as needed from this point forward. Owners reported that they rarely had to give the carprofen at this point, as Sam seemed relatively comfortable at home. Sam was also on limited activity. It was recommended that the owner try to cut out stairs and not to allow running and jumping, but she was able to walk around the home and briefly outside. Sam has a laid back personality and adhering to this was not an issue for the owner. Electropuncture was attempted early in the treatment. However, Sam became very anxious even when the frequency and intensity was set very low. Therefore, this treatment was discontinued and her treatment was limited to dry needling and photomodulation.
I learned from this case that surgery is not the only option for dogs that have cranial cruciate ligament tears. Significant improvement can be maintained with acupuncture, photomodulation, exercise plan and NSAIDs. This case study shows that surgery is not necessary to achieve a positive result permitting the dog to return to full function. Cranial cruciate ligament injuries are one of the most common injuries seen in private veterinary practice and being able to offer clients a more conservative approach to recovery is very beneficial.
Citations
David M Lane and Sarah A Hill (2016). Effectiveness of Combined Acupuncture and Manual Therapy Relative to No Treatment for Canine Musculoskeletal Pain. The Canadian Veterinary Journal, vol 57(4), p 407-414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4790233/
Nuno E.O.F. Silva et al (2017). Effect of Acupuncture on Pain and Quality of Life in Canine Neurological and Musculoskeletal Pain. The Canadian Veterinary Journal, vol 58 (9), p 941-951. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556488/