Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017055
Abstract: An adult Friesian mare presented for hind end lameness and generalized muscle soreness secondary to chronic bilateral stifle and hock joint pain. The patient was dry needled three times at two-week intervals to help manage her discomfort. After treatments, myofascial palpation indicated improved comfort and dynamic examination indicated improved gait quality. Due to the patient’s positive response, acupuncture has been incorporated into her monthly management.
History and Presentation: Aurora, a 14-year-old Friesian mare, has a history of bilateral hock and stifle pain. Aurora has had chronic intermittent episodes of lameness over the past several years and flexes mildly positive to each of these joints. Radiographs indicate mild osteoarthritic changes to these joints. Aurora’s hocks were first injected in 2015 and have been subsequently maintained with joint injections every 6-12 months. Aurora does well following intra-articular treatment with corticosteroids and hyaluronic acid for a few months and then shows signs of stiffness and discomfort.
Physical Examination and Clinical Assessment: Examination of Aurora’s conformation indicated an overdeveloped front compared to her less developed hind end. Aurora’s general musculature was bilaterally symmetrical. Myofascial palpation of her neck, dorsal aspect of her shoulders and back indicated severe tenderness and taut bands. Trigger points were appreciated along her thoracolumbar and lumbosacral areas, particularly along the bladder line. Evaluation of her feet showed under-run heels with shoes that lacked caudal heel support. Dynamic exam indicated that Aurora moved by pulling from her forelimbs rather than pushing from her hinds. Aurora showed a grade 2/5 bilateral hind lameness. Flexion tests were positive on both upper hind limbs.
Medical Decision Making:
Based on myofascial palpation, Aurora had significant muscle pain from traveling abnormally to compensate for her joint discomfort. The goals of acupuncture treatments were to improve comfort and reduce the frequency in which she needed invasive joint maintenance. Many of the points selected for dry needling were located around areas with tight bands or trigger points. These points were selected for treatment to reduce sensitization of peripheral nociceptors and minimize referred pain and muscle tension in these areas (Edwards and Knowles). By activating A delta and C fibers with dry needling, the goal was to inhibit dorsal horn interneurons, to promote tissue release and relaxation, and to increase blood flow to these large muscle bodies for improved oxygenation and healing. Based on the chronicity of Aurora’s pain, another focus of treatment was to reduce wind up (Cheng). Lastly, given that Aurora had never received acupuncture and was a difficult mare to handle, many permission and parasympathetic points were used.
Differential Diagnoses: Muscle pain secondary to joint osteoarthritis, Exertional Rhabdomyolysis, or primary myopathy.
Definitive Diagnosis: Muscle pain secondary to hock and stifle osteoarthritis was considered most likely based on myofascial palpation, lameness exam including flexion tests, chronic intermittent lameness, and radiographs of her hocks and stifles.
Acupuncture Treatments: Using 0.25mm Seirin needles, three dry needle treatments were performed at two-week intervals beginning at the end of April 2017. Given Aurora’s personality, I began with permission points GB 21 and Bai Hui, adding LI 16 as these points are favorable in most horses. As Aurora began to relax, I added needles to the trigger points I palpated near BL 18, BL 23, BL 25 and BL 27. My goal with these points was to modulate spinal nerves associated with thoracic, lumbar and sacral regions, thereby relieving lumbosacral pain and sacroiliac dysfunction. I also included BL 54 for hip pain. I used GB 33 for more specific stifle pain. I added GV 14 and ST 36 to provide parasympathetic support. BL 62 was used in the third treatment to modulate the fibular and tibial nerves and decrease tarsal pain. Lastly, I included shoulder points TH 14 and BL 13 to help with pain in this area, given Aurora’s tendency to pull from her forelimbs.
Outcomes, Discussions, and References: Aurora was reported to be mildly stiff the first day after treatment. However, Aurora showed subsequent improvement in the following days after dry needling. She was less sensitive to palpation, moved more comfortably, and had a generally more positive attitude. Overall, dry needling Aurora at two week intervals improved her comfort significantly enough that with monthly treatments, the frequency in which joint injections are needed will likely be decreased.
Cheng, KJ. (2009). Neuroanatomical basis of acupuncture treatment for some common illnesses. Acupuncture in medicine, 27, 61-64.
Edwards, J., & Knowles, N. (2003). Superficial dry needling and active stretching in the treatment of myofascial pain- a randomized controlled trial. Acupuncture in medicine, 21 (3), 80-86.