Written by a Medical Acupuncture for Veterinarians course graduate.  Signed release obtained from client/author. 10D2017001

Abstract: WR Sunwolf (“Sunny”) is a 13 year old Morgan gelding who presents for concerns over degenerative joint disease and an abnormal tail carriage.

History and Presentation: Sunny was diagnosed radiographically with degenerative arthritis in his hind pasterns (ringbone) in 2016. He was acquired by his current owner at this time and there is minimal medical history available before this. It was reported by the previous owner that Sunny sustained some sort of tail injury but no other information was available. The previous owner did have coccygeal radiographs performed sometime in 2011 which demonstrated no fractures or luxations to the area. However after this point Sunny persisted in carrying his tail head to the left.

Other Medical History/Treatments: The current owner has putatively diagnosed him with bilateral hock arthritis and ulcerative gastritis that flares with stress. Otherwise Sunny is in good health. He is dewormed twice yearly, floated once yearly, and kept up to date on vaccines. His current medications/supplements include Stress Relief by Redmend Gold, Amplify (high fat supplement), and omeprazole as needed.

Physical Examination and Clinical Assessments: Sunny is bright, alert, and responsive and vitals are within normal limits. Sunny resists having his left pelvic limb raised and is heavy on this limb. His cervical lateral flexion is excellent. Lateral manipulation of his withers (T3-T6) is normal. He displays possible mild restriction in lateral manipulation of his lumbar vertebrae although his thoracolumbar extend and rotate is within normal parameters. Sunny’s flick test is normal. Forelimb manipulation reveals discomfort on extension of fetlocks and pasterns bilaterally. He also demonstrates lack of dorsal scapular movement of the left thoracic limb. Hindlimb manipulation reveals lack of pelvic drop with right pelvic limb circling. He also moderately resists right pelvic limb circling. Sunny’s neurologic exam is unremarkable. Sunny has a mostly unremarkable gait at the walk and trot, however a lack of right hip drop is appreciated during ambulation. Sunny’s myofascial examination reveals unilateral reaction to gentle pressure at left ST-7 and myofascial restriction over lumbosacral longissimus dorsi mm bilaterally. He also displays hypertonicity with tenderness of the left lateral head of triceps brachii mm and is reactive to palpation of right cranial gluteal mm and over right hindquarter.

Medical Decision Making: I discussed my myofascial examination and joint mobilization findings which localize his dysfunction to his right sacroiliac or coxofemoral region. Further imaging such as ultrasound or radiographs would be indicated to further delineate which region is the primary region of dysfunction/disease. The client’s goals are to provide pain relief to Sunny and possibly be able to ride him again as a pleasure horse. Recommend weekly acupuncture and cold laser treatments of abnormal areas for a minimum of 3-4 weeks then reassess. I think Sunny has a fairly good chance of reacting positively to these integrative medicine modalities. I also discussed Sunny’s positive response to palpation of ST-7 on the left side and how this can indicate oral or dental pain.

Differential Diagnoses:

Lumbosacral, Left Forelimb, and Right Hindlimb Stiffness/Pain
Vascular – ischemic injury, thromboembolic insult, fibrocartilaginous infarct
Infectious/Inflammatory – diskospondylitis, myositis, neuritis, physitis, arthritis (infectious/sterile/rheumatoid)
Neoplastic/Neurologic – IVDD, various sarcomas, carcinomas, round cell tumors
Degenerative – diskospondylosis
Iatrogenic/Intoxication
Congenital
Autoimmune – rheumatoid arthritis
Trauma – traumatic IVDD, fracture, luxation, dislocation
Endocrine/Metabolic
Myofascial Dysfunction – longissimus dorsi mm, left lateral head of triceps brachii mm, right cranial gluteal mm, right biceps femoris mm

Abnormal Tail Carriage
Vascular – ischemic injury, thromboembolic insult, fibrocartilaginous infarct
Infectious/Inflammatory – myositis, neuritis
Neoplastic/Neurologic – nerve injury, nerve sheath injury
Degenerative – osteoarthritis
Iatrogenic/Intoxication
Congenital
Autoimmune – rheumatoid arthritis
Trauma – fracture, luxation, dislocation, soft tissue/nerve injury
Endocrine/Metabolic
Myofascial Dysfunction

Definitive (or Putative) Diagnosis (or Diagnoses):
1. Myofascial dysfunction of lumbosacral junction, longissimus dorsi mm
2. Established degenerative arthritis (ringbone) of bilateral hind pasterns
3. Myofascial dysfunction of right SI and/or coxofemoral joint
4. Myofascial dysfunction of left forelimb with putative arthritic changes in bilateral fetlocks and pasterns

Acupuncture Treatments: Sunny was treated once weekly for three weeks with acupuncture, low level laser therapy, and joint mobilization. Acupuncture was administered with a mixture of 0.30x40mm, 0.20x40mm, and 0.25x40mm Seirin coated needles. Each treatment lasted approximately 30 minutes. Each treatment began with several parasympathomimetic points including GB-21, LI-16, and Bai Hui in order to help Sunny relax. I also typically attempted to place LI-17, SI-16, LI-15, and TH-14 near the beginning of the treatment as these tend to be less sensitive points in the equine patient. LI-15 and TH-14 were also beneficial in treating the left forelimb scapular restriction via their relation to the suprascapular nerve and associated soft tissues (infraspinatus and supraspinatus muscles). SI-9 was also employed due to its relation to the axillary and radial nerves as well as the lateral and long heads of the triceps brachii muscle. Per my myofascial examination, several BL points were treated depending on areas that exhibited hypertonicity and/or tenderness that day – typical points employed included BL-20, BL-21, BL-22, and BL-23 (all midthoracic spinal nerve stimulants). In order to address the right hindlimb dysfunction and stiffness, BL-27 and BL-28 were treated to provide stimulation of the sacral spinal nerves before they course down the pelvic limbs as well as provide neuromodulation to the sacroiliac junctions. Per my myofascial findings, BL-29 and BL-54 were treated for the cranial gluteal muscle hypertonicity and tenderness. These points could also provide stimulatory benefit to the area around the coxofemoral region. Due to tenderness to examination over the biceps femoris and general hindquarters, BL-30 and BL-40 were treated to provide neuromodulation of the sciatic nerve. Sunny also received low laser treatment with a SP 910nm 3 J/cm2 over SI joints.

Outcomes, Discussions, and References: During each treatment session while Sunny had the needles placed, his tail would correct to an almost normal orientation (perhaps 10 degrees lateral variance). His tail also reacted positively to manual stimulation (scratching to the right of the tail head) but would resume its abnormal orientation once stimulation manually or with needles was ceased. The client noted he moved much easier after his treatments. He also exhibited less restrictive motion of this right hip during walk/trot gait analysis. Over the course of treatments Sunny’s myofascial restriction in his left triceps brachii and longissimus dorsi mm resolved 90%. I suspect with further treatments he will continue to improve. He also experienced marked improvement of his left scapular dorsal movement and right hind circling. At second treatment he did react unilaterally to both ST-7 palpations – emphasized to owner concern over possible oral/dental disease.


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