Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017050
A patient had presented to me for non-weightbearing after being improperly diagnosed as a musculoskeletal problem at another veterinary clinic. After more thorough diagnostics and a trial of medications, acupuncture was started which relieved the patient’s neurologic signs so that he was able to walk normally again.
History and Presentation
Leonard is a 3 year old male neutered domestic short hair cat who was presented to me on 8/5/17 for licking his left carpus raw. In May, Leonard’s owner found a puncture wound on one of his paw pads on the left forelimb. He began to lick his paw raw. Over the course of two weeks, Leonard became progressively more lame to the point of non-weightbearing. He was brought to several veterinarians over the course of May, June, and July. At first, an autoimmune disease was the supposed diagnosis, and Leonard was put on a course of prednisolone and was instructed to wear a cone. After two weeks, the wound had healed, but Leonard was weaned off of his prednisolone after no noticeable improvement in the limping. He would attack his foot any time that his cone was removed. He began acting depressed and would hide, so amitriptyline was tried instead. Gabapentin was added when he continued to be lame. It was noted that palpation of the left medial coronoid process elicited a repeatable pain response. A single lateral radiograph of the left forelimb was taken and Leonard was diagnosed with elbow dysplasia. All medications were eventually stopped and Leonard was presented to me.
Physical Examination and Clinical Assessments
Leonard had licked his left carpus raw, to the point that there was an open, ulcerated lesion. The left forelimb was constantly supinated, and if Leonard placed weight on the limb, he flicked the limb forward, scuffing the top of his left paw before he placed the paw down. Leonard could flex and extend his elbow well voluntarily. Conscious proprioception was absent in this limb. All other physical exam parameters were within normal limits. No pain was elicited on full orthopedic examination. He was not on any current medications.
Medical Decision Making
I did not see any pathology on the radiograph by which the previous veterinarian had diagnosed with Leonard with elbow dysplasia. Therefore, I recommended 2 view radiographs of both thoracic limbs to compare. Surprisingly, the left forelimb looked normal, and the right elbow displayed questionable arthritic changes. I sent Leonard home on Gabapentin, Buprenorphine, and Clavamox for 10 days. The owners were instructed to keep a cone on him at all times. Acupuncture was discussed, but the owners declined at that time.
Leonard presented again on 8/14/17 for a recheck examination. Leonard had stopped excessively grooming and his skin had healed well. However, he was still not bearing any weight on his left forelimb despite the pain medications. I then focused on treating the neurologic deficits he was experiencing. Pain medications were discontinued and acupuncture was started. No trigger points were found during any of the treatments.
Due to the neurologic deficits and lack of apparent musculoskeletal pathology my top differential diagnosis was nerve damage. Alternatively, there could be a nerve sheath tumor or an orthopedic condition not seen on radiograph.
Definitive (or Putative) Diagnosis (or Diagnoses)
Open, suspect nerve damage due to neurologic deficits and lack of abnormalities on palpation and radiographs
0.16 nano tech needles; needles placed 20 minutes
LI15->LI4 left forelimb estim 15 minutes mixed stimulus 5/100 Hz
Outcomes, Discussions, and References
After one session of acupuncture, Leonard began walking on his affected limb at home. He even used it to open a kitchen cabinet and was acting much more loving than he had been in recent months. This lasted for a few days and then he began to stop using it again. He visited weekly week for two more sessions and by the end, was walking well on the limb. His conscious proprioception was still absent, however. Unfortunately, after the third treatment, Leonard’s owners stopped coming in for treatments, and they would not answer my phone calls. I later looked at his electronic record and saw that we had received records that he had been euthanized for unrelated causes at an emergency clinic a month after he had stopped seeing me. I was not able to take a picture of him before he was euthanized.