Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018031

Abstract
“Tater” was presented for history of left cranial cruciate injury of two year duration. After injury Tater exhibited pain, lameness, and altered gait. Surgical repair of injury was not an option at the time, and rest and Dasuquin were recommended. At initial presentation, Tater’s gait was abnormal and pelvic limbs appeared hyperflexed when walking, and demostrated compensatory changes on all other limbs, midback, and neck. After acupuncture treatments, which included dry needling and massage, lameness has resolved, gait has improved, patient appears more comfortable, and the only supplement Tater is taken is Dasuquin. Tater will continue acupuncture treatments as needed to maintain his new and improved quality of life.

History
Tater is a 6.5 year old (BOD 11/25/2011) male castrated Shih Tzu mix, presented for history of left cranial cruciate injury. Injury occurred two years prior to presentation, and surgical repair was not an option at the time. Currently, Tater experiences intermittent lameness, especially after exercising, and he is taking Dasuquin at maintenance dose. Tater had a dental prophylaxis on 5/18/18 with extraction of 204, 101, and 201, and unremarkable pre anesthetic blood work. Tater is up to date on his core vaccines (rabies, DA2PP), has tested negative for heartworm disease, and eats Purina one dry adult formula.

Beforevideo7     Beforevideo1

Physical Examination and Clinical Assessments
BAR. T – 100.4, P – 100, R- 50. MM – Pink and moist, CRT <2. BCS 5/9. Wt – 18.7lb
Eyes and Ear – NSF
Oral – No tartar, missing teeth, no gingivitis
Integument – NSF
Lymph Nodes – NSF
Cardiopulmonary – Normal sinus rhythm, strong synchronous pulses. Normal bronchovesicular sounds; cough was not elicited with tracheal manipulation, no nasal discharge.
Abdomen – soft and not painful. No overt organomegaly or masses.
Neurological – Normal CN, PLR, and menace flexes. Normal panniculus reflexes and anal tone. Negative withdraw reflexes all four limbs. Normal CP, extensor postural thrust, hopping all limbs. Thoracic limbs (TL) – Normal Biceps, Triceps, and Extensor Carpi Radialis reflexes. Pelvic limbs (PL) – Normal Patellar and Tibial Cranialis reflexes. All limbs – Normal superficial and deep pain.
Musculoskeletal – Lameness was not observed during examination. Normal gait, but pelvic limbs appear dropped when walking and trotting. Neck – normal ROM. Lumbar region – uncomfortable on palpation. Thoracic limbs – Normal muscle mass, normal ROM all joints, and not painful on examination. PL’s – Normal muscle mass both limbs. Hips- Decreased ROM on extension and abduction. Left PL – Stifle – Laxity, uncomfortable on palpation, especially on flexion, positive drawer, moderate medial buttress, decreased ROM on extension. Hock and digits appear WNL. Right PL – Stifle – uncomfortable on palpation, more on flexion of joint; however, unable to elicit drawer, slightly decreased ROM, especially on flexion. All other joints appear WNL. Radiographs – Spine appears within normal limits, no indications of spondylosis or changed intervertebral spaces. Coxofemoral Joints – Right – decreased joint space in dorsal aspect of joint, all skeletal structures appear within normal limits. Left – Head of the femur is not centered in the acetabulum and is flattened, joint space is much narrowed, and cranial edge of the acetabulum is flattened and has some periosteal proliferation, mild bone lysis on the head of the femur. Stifles – Right – Mild periosteal proliferation, narrowing of joint space on medial aspect, early perichondral osteophyte formation on craniolateral tibia, and mild enthesophyte formation of distal tibia and proximal femur. Left – Mild joint effusion with craniad shift of fat pad, very narrowed joint space with medial aspect of joint worse than lateral, perichondral osteophyte on the cranial aspect of the tibia, enthesophyte formation, bone lysis and periosteal proliferation of distal aspect of femur and dorsal aspect of tibia. Thorax – skeletal structures appear WNL, heart is of normal shape and size (VHS 9.5), lungs and mediastinal structures do not show any significant findings. Stomach has ingesta in it, some gas and thickening of small intestine, large urinary bladder, and stool in colon.
Myofascial Exam –
1. Normal muscle mass on face and head. Temporomandibular joint – not painful normal ROM. Trigger point (TrP) on cranial aspect of left Masseter muscle, and mild restriction of the fascia of the head
2. Normal muscle mass and ROM neck – patient followed treat and owner in all directions without eliciting pain or vocalization. However, Sternomastoideus and Trapezoid muscles are very tight
3. Trigger points on both Brachiocephalicus muscles proximad to the clavicular tendon. Taut band on left long head of the Triceps brachii and trigger point on left lateral head of the Triceps brachii. Omobrachial fascia restriction.
4. Taut bands along Latissimus dorsi over the lumbar region, on both side of the spine. Thoracolumbar fascia restriction along the Longissimus thoracis and lumborum muscles.
5. Very tight iliopsoas bilateral, patient is very uncomfortable when examined.
6. Bilateral myofascial restriction of the lateral femoral and hamstrings myofascia. Bilateral Quadriceps femoris changes– Taut bands on the Vastus lateralis, and trigger points on the Rectus femoris. However changes are more pronounced on the left PL. Mild decreased in muscle mass of left Hamstrings with trigger points and taut band in the Semimembranosus muscle.

Differential Diagnoses
Intermittent lameness left pelvic limb – Rule outs – Cranial cruciate tear – chronic, soft tissue injury, degenerative joint disease, osteoarthritis.
Hip dysplasia – Right coxofemoral joint.

Definitive/Putative Diagnosis
Left cranial cruciate disease with compensatory changes of all other limbs and back is the putative diagnosis after physical and myofascial exams. Left cranial cruciate disease is diagnosed by the physical, myofascial, and radiographic changes in the left stifle. These changes are manifesting as intermittent lameness, stifle pain, laxity, and positive drawer. Also, radiographic changes are consistent with chronic cranial cruciate disease. Lateral femoral and hamstring myofascial restriction, tight iliopsoas muscle, decreased hamstrings muscle mass, trigger points and taut bands in hamstrings and quadriceps muscles are myofascial changes seen with cranial cruciate disease. Compensatory changes are manifest as tight right iliopsoas muscle, right lateral femoral myofascia restriction, and trigger points and taut bands in the hamstring and quadriceps muscles. Restricted thoracolumbar myofascia, taut band, and trigger points are consistent with compensatory changed of the lumbar spine.

Medical Decision Making
Acupuncture, medical massage, and supplements are recommended for this patient, and there is no access to Laser and electro-acupuncture due to the nature of the practice. At this time, only orthopedic changes will be addressed, since patient appears otherwise in good health. Acupuncture treatments will address primary injury of left stifle and right hip, and compensatory changes in the rest of the body. Treatments are formulated to modulate the central and autonomic nervous systems, as well as peripheral changes. Central and peripheral neuromodulation will utilize channels involving Femoral and Sciatic nerves thorough Saphenous, and Fibular and Tibial nerves respectively. Autonomic nervous system neuromodulation will make use of channels associated with the Fibular, Trigeminal, and Spinal nerves. Taut bands and trigger points will be treated individually as allowed by patient. Myofascial release, dissolving taut bands and trigger points, decrease of pain and inflammation are the connective tissue changes expected from the above neuromodulation.

Treatment
Treatments will start with effleurage massage, to help assess myofascia and muscle condition, and prepare patient for dry needling. They will also finish with effleurage helping venous blood flow, and ensuring all needles are removed.
Needles – 16 mm diameter, 15 mm and 30 mm in length, Seirin needles for all trearments
Points selected will include:
1. Central Nervous System – These points are used to neuromodulate CNS and to address some of the taut bands along the epaxial muscles. Bai Hui, BL 10, BL23-27.
2. Peripheral Nervous System – These points address local muscular and myofascial changes. Left pelvic limb – ST34, ST36, BL36, ST40, BL 60, Right pelvic limb – SP9, SP10.
3. Autonomic Nervous System – Thes points are utilize to decrease inflammation, provide analgesia, and decrease stress. LR2, GV20, GV14, ST36, BH.
4. Myofascia TrP’s – Trigger points on right and left brachiocephalic and Quadriceps femoris muscles. Taut bands on biceps brachii and Semimembranous muscles.
July 9, 20018 – Second treatment – BAR, T–101.1, P-120, R-Pant. Wt- 18lb
Myofascial Exam –
1. Neck -Sternomastoideus and Trapezoid muscles are tight, but improved form previous week.
2. Trigger points on both Brachiocephalicus muscles proximad to the clavicular tendon. Tater does not appear to respond as strongly as last week to palpation.
3. Several short taut bands, instead of one long one, along Latissimus dorsi over the lumbar region, on both side of the spine. Mild Thoracolumbar fascia restriction along the Longissimus thoracis and lumborum muscles.
4. Iliopsoas is not tight, and patient is not reactive when examined.
5. Bilateral myofascial restriction of the lateral femoral and hamstrings myofascia. Bilateral trigger points on the Rectus femoris. Mild decreased in muscle mass of left Hamstrings with trigger points and taut band in the Semimembranosus muscle bilateral.
Points selected:
1. Central Nervous System – Bai Hui, BL10, BL13-15, BL23-28.
2. Peripheral Nervous System – Both sides: GB20, BL36, BL60, LR2, BL54, GB29, GB30, SP9, SP10, LI4 Left pelvic limb – ST34, ST36.
3. Autonomic Nervous System – LR2 (right PL), GV14, ST36, BH, LI4.
4. Myofascia Trigger Points – Trigger points on right and left brachiocephalic, Quadriceps femoris, and Semimembranous muscles. Iliopsoas muscle massage.
July 16, 20018 – Third treatment – BAR, T–100.5, P-110, R-40. Wt- 18.4lb
Myofascial Exam –
1. Neck -Sternomastoideus and Trapezoid muscles are again very tight.
2. Short taut bands along Latissimus dorsi over the lumbar region, on both side of the spine. Thoracolumbar fascia restriction along the Longissimus thoracis and lumborum muscles is much less that on previous week.
3. Iliopsoas is not tight, and patient is not reactive when examined.
4. Bilateral myofascial restriction of the lateral femoral and hamstrings myofascia; however, not as restricted as previous two weeks. Bilateral trigger points on the Rectus femoris. Mild decreased in muscle mass of left Hamstrings with trigger points in the Semimembranosus muscle bilateral. Trigger points on both Gastrocnemius muscles.
Points selected:
1. Central Nervous System – Bai Hui, BL10, BL13-15, BL19, BL20, BL23-28.
2. Peripheral Nervous System – Both sides: GB20, LI4, LI11, BL36, BL60, LR3, BL54, GB29, GB30, SP9, SP10, ST34, ST36.
3. Autonomic Nervous System – LR3, GV14, GV20, ST36, BH, LI4.
4. Myofascia Trigger Points – Trigger points on right and left Biceps brachii, Quadriceps femoris, Semimembranous, and Gastgrocnemius muscles. Massage of Iliopsoas muscle.

Aftervideo2        Aftervideo1

Outcomes, Discussion, and References
Significant improvement has been noticed, by owner, in Tater’s quality of life. Owner reports a more active dog, with not lameness after exercising, since acupuncture treatment has been implemented. Myofascial exam also shows improvement as trigger points have dissolved and taut bands are shorter and less painful on exam, myofascial restriction and hyperflexion of pelvic limbs has improved, compensatory changes have been almost completely corrected, muscle tightness has decreased significant. However, one interesting finding is that as some of the original myofascial and muscular changes are treated and resolve, other changes are discovered. For instance, Gastrocnemius TrP’s were not evident until last treatment. In conclusion, acupuncture treatments benefit Tater Guzman’s overall well-being, as he is a more active, pain free pet. Maria, Tater’s mom, is very happy to have Tater participating in more family activities without experiencing pain. Tater will continue to receive acupuncture treatments, as needed, to maintain him active and pain free.
References
CURACORE. Integrative Medicine & Education Center. (2018), accessed 6 July 2018, <https://curacore.litmos.com>
Robinson, N, and Sheets, S. (2015). Canine Medical Massage. Techniques and Clinical Applications. Lakewood, Colorado: American Animal Hospital Association Press.
Evans, H. (1993). Miller’s Anatomy of the Dog. Ithaca, New York: W.B. Saunders company.
Thrall, D. (2007). Textbook of Veterinary Diagnostic Radiology. St. Louis, Missouri: Saunders Elsevier.


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