Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017011
Princess Peaches, a juvenile female pygmy goat, presented for deformity and disuse of her left forelimb. Radial nerve paralysis and carpal valgus and limb contracture were diagnosed. The patient was hospitalized and acupuncture, stabilization and intensive physical therapy were instituted for 4 days. Patient responded well to therapy and began using leg. Patient returned weekly for two more visits for acupuncture treatment and follow up. At last recheck, Princess Peaches was comfortable and ambulatory on the leg.
History and Presentation:
Princess Peaches is a approximately 6-8 weeks (actual age unknown) old intact female pygmy goat who presented to the Livestock Medicine service 5/8/17 for carpal deformities. Owner acquired patient during a birthday party for their grandson at a petting zoo. The zoo was going to euthanize Princess due to her limb deformity so the new owner adopted her. There is no previous history available as to when the deformity became apparent/if it was present at birth. Also no history on whether the birth was difficult and if kidding was assisted. No history on colostrum ingestion or previous illness as a neonate. Owner brought patient to the rDVM for a general check up as she was going to be an indoor goat for their grandchildren. rDVM took fecal sample and found eimera and giardia. Treated with fenbendazole and sulfadimethoxine “albon”. Clinic ran out of albon thus patient still need 3 more days of treatment. Despite not being able to use the limb, the patient is able to run, jump and even climb stairs. However, she does get tired quickly but does not seem to be painful. No V/D/C. Occasionally sneezes. Vaccinations: CD+ T given at rDVM. Diet: bottle feed milk replacer BID-TID 120cc, grass hay and salt. Environment: Indoor/outdoor pet goat. A dog will be joining the family.
Physical Examination and Clinical Assessments: GEN: BAR, cooperative and energetic T:101.3 P:132 bpm R: 48 breaths/min BCS:3/9. MM: Pink, moist with CRT < 2 seconds.
Cardiovascular: No murmurs or arrhythmias, femoral pulses strong and synchronous with heart beat, distal extremities warm.
Respiratory: Eupneic; normal bronchovesicular sounds bilaterally; no crackles/wheezes Ocular: No discharge noted; cornea, lens clear
ENT: Facial expression symmetrical; no odor or discharge from nares, ears freely moveable Integument: Hair smooth and intact.
Gastrointestinal: Abdomen soft and non-painful on palpation
Genital: Intact female.
Neurologic: Appropriate mentation. Cranial nerves normal. Dropped left elbow, unable to fix carpus. No withdrawl response left front. Difficult to assess sensation as patient is constantly moving, chewing on clothing and instruments, however lack of withdrawal seems to be from lack of ability to withdraw rather than lack of sensation.
Musculoskeletal: Ambulatory, not full weight bearing on the left front. Walking and standing with the left hoof pointed laterally, carpus bent, placing some weight on the medial toe. Elbow is dropped and toe drags when she moves. Left carpal valgus, contracture at carpus and fetlock, unable to place heel on ground. Carpus is non-painful on palpation, able to flex carpus, full extension not possible. No palpable joint effusion.
Lymph nodes: No enlargement of LN
Problem list: Left front limb contracture, carpal varus, and signs consistent with radial nerve paralysis. Also historic coccidia infestation dx by rdvm.
Medical Decision Making:
Possible causes of limb contracture in a juvenile animal could be congenital malformation, or disuse from injury, infection, or weakenss. Radiographs were taken to rule out congenital malformation or evidence of bony changes consistent with a septic joint.
Radiographic report: There is mild flexion and valgus of the left carpus. No osseous abnormalities are identified. Mild left flexor tendon contracture and carpal valgus may be due to a traumatic or congenital etiology.
Possible causes of radial nerve injury are difficult kidding with excessive traction placed on front limb, limb getting caught in fencing or other structure and causing nerve injury, excessive time spent in lateral recumbency and nerve compression. The patient was so small and light that nerve compression due to recumbency was unlikely, even without knowing if she had a history of illness. Since limb problem seems to have been present since birth, a kidding injury is most likely.
My first goal for acupuncture treatment in this case was to stimulate the radial nerve (LI channel) and other nerves of the brachial plexus (BL11,12,13) that may have also been damaged by excessive traction during the birthing process. My second goal was to address the contracture by affecting the muscles and connective tissue, both by stimulating extensors, but also attempting to relax flexors to allow the tendons to stretch. My third goal was to address pain, both from chronic abnormal weight bearing (BL 21/23, latissimus dorsi insertion points), but also from our physical therapy (GV 14, 4, Ba hui). As she was a wiggly young animal, intent on chewing everything, I avoided points on the limbs, or anywhere that she would easily reach. If I had access to laser, I would have treated some distal points using that modality.
Other treatments that we instituted were physical therapy which included stretching, passive range of motion and withdrawals (pinching toes gently to make her withdraw her leg), splinting her limb straight over night, and pain control.
Differential Diagnoses: Injury during kidding, septic process, congenital malformation.
Definitive (or Putative) Diagnosis (or Diagnoses): Kidding injury resulting in radial nerve injury and disuse of limb, resulting in contracture.
Day 1: Acupuncture: BL 11,12,13, Th14, LI16, 15, 11. GV 14, Ba hui. (attempting to stimulate radial nerve, nerves of brachial plexus.) Patient extremely wiggly and chewing on everything, so conservative needle placement was used to avoid needle ingestion.
Day 2: PE: bearing slight weight on foot, withdrawal response improved, sensitivity/trigger points at base of left neck. TX: GV14, GV20, Baihui attempted but too sensitive, BL 11,12,13, LI16, 15, 10. Electro: LI 15-10 10 minutes 5hz. Patient was again extremely wiggly, but calmed down and slept during the electro.
Day 3: Acupuncture: GV 14, 20, BL 11,12,13, LI 16, 15, 11, 10. Electro: LI 16-10, 15-11, 5hz 10 min.
Non acupuncture treatments included: Splinting leg overnight to stretch flexor tendons, Meloxicam for pain control, and passive range of motion during the day.
Patient discharged, able to withdraw limb and place weight on limb at a walk.
1 week recheck: Owner states Princess Peaches is using leg all the time now, even when she runs, he continues to do passive range of motion excercises at home and splint the leg at night. Carpus has some instability. We advised to discontinue the splint to let the carpus strengthen up more. Acupuncture Exam: trigger points around bladder 21,23 on right side. LF has good range of motion, except for slight contracture at carpus, developing some laxity at fetlock. Acupuncture: LI 16, 15, 11, 10, BL11, 13, 21, 23, GV 14, 4. Electro LI16-11, LI 15-10 5hz 5 min, 50hz 5 min.
2 week recheck: Fully weight bearing, no carpal instability, still slight contracture at carpus which may be worse since discontinuing splint. It is especially evident when she is standing. Advised owners to continue stretching her leg when they are holding her. Withdrawal response normal. Acupuncture: LI 16, 15, 11, 10, BL11, 13, 21, 23, GV 14, 4. Electro LI16-11, LI 15-10 5hz 5 min, 50hz 5 min.
Outcomes, Discussions, and References:
Acupuncture definitely affected the outcome of this case, I have treated limb contracture and radial nerve paralysis before using the same physical therapy and pain control as was implemented in this case, and have never seen such dramatic improvement so quickly. According to the history that we could piece together over several conversations with the owner, it seems possible that this animal had never used her limb since birth, and when we saw her she was approximately 2 months old. Limb contracture in small ruminants occurs quickly with disuse, and becomes difficult to reverse, especially if the muscles needed to fix the carpus (triceps) are without appropriate innervation, as was in this case. I am very pleased with the outcome in this case, as she will be a fully functional pet for the little boy who owns her. She may be at risk for osteoarthritis in that joint when she is older, from abnormal weight bearing. Unfortunately, Princess Peaches was lost to follow-up after her last visit, she was being brought in by the grandfather of the little boy who owned her and he was in poor health. He had to undergo some surgical procedures and we did not hear from them after that.
There are descriptions in the literature of using acupuncture for radial nerve injury:
1. Millea PJ. Acupuncture treatment of compression neuropathy of the radial nerve: a single case report of “Saturday Night Palsy”. J Altern Complement Med. 2005 Feb;11(1):167-9.
2. Zhang Gui-xiang. Acupuncture plus TDP treated 34 cases of radial nerve paralysis. Journal of Acupuncture and Tuina Science. February 2003, Volume 1, Issue 1, pp 46–47
This second paper utilized many of the same points that I used in this case, which I found really interesting from a comparative anatomy perspective.