Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017056
Abstract: Prix is a young dressage horse with sacroiliac (SI) pain and mild right hind lameness most likely attributable to the stifle joint. These issues have affected her performance. She has been treated with several modalities, but has shown the most improvement after SI methylprednisolone acetate (Depo-Medrol) injections and acupuncture.
History: Prix is a 7 year old Welsh Cob x Arabian mare. She was purchased by her current owner in November, 2016. Prix is a dressage horse and is currently training at second level and showing at first level. They are hopeful she will continue up the levels, possibly even to the Fédération Equestre Internationale (FEI) level. She had a pre-purchase exam performed in Texas. This veterinarian reported mild effusion in the right front fetlock joint and a 1+ positive response to flexion test of this joint. She was sound at the trot and right lead canter, but had a mildly shortened stride with the right hind in left lead canter. The veterinarian reported “no sensitivity upon thoracolumbar (T/L) and lumbosacral (L/S) epaxial muscle palpation and acupuncture points“. Radiographs were taken. There were no abnormalities found in the right front fetlock. Her right stifle views showed mild flattening of the medial femoral condyle with appropriate joint space. Prix was purchased and shipped to Colorado. Upon arrival her owner noticed Prix was stiff through her back. Once they started riding, she noticed difficulty picking up and maintaining the left lead canter and she could hear a clicking sound in her right hind stifle area, possibly indicating intermittent upward fixation of the patella (IUFP). Prix then started bucking when asked to pick up the lead. She had some chiropractic work done and had one interleukin 1 receptor antagonist protein (IRAP) injection in the right stifle. They winter in Florida, so Prix was hauled to Florida in December, 2016. After this trailer ride, she was again stiff and painful, evidenced by stretching out her lower back and stopping her hind feet. In Florida the issues with her right hind continued so she was started on weekly Estrone Sulfate injections (treatment for the suspected IUFP). There was little improvement. The owner started physical therapy riding (hill work, long trotting, backing, ground pole work) and worked on saddle fit issues. Her hocks were injected. Again, little improvement was seen. They returned to Colorado in April, 2017. The owner had Colorado State University’s Equine Sports Medicine team out to evaluate Prix on June 6, 2017. They diagnosed SI pain and right hind lameness-open diagnosis (further diagnostics were recommended, but the most likely source was thought to be the stifle joint). Her SI joints were injected and she was prescribed methocarbamol and core strengthening and rehabilitation home exercises. Prix was also recently started on altrenogest (Regu-Mate) to help regulate her estrous cycles during the show season.
Physical Exam (PE) and Clinical Assessments: I first evaluated Prix on June 19, 2017. She was slightly overweight with a Body Condition Score of 6+/9. She was well muscled and in good condition. She was tender to palpation at both right and left ST 7. She was reactive at BL 20-21 bilaterally and from BL 26-30 bilaterally. She was also tender at both SI 9 areas. She was mildly reactive from ST 10 along the brachiocephalicus muscle to the base of her neck on the right side. She had muscle tension and tenderness at her T/L longissimus and iliocostalis muscles, her left deltoid and infraspinatus muscles and her right trapezius muscle. She was moderately reactive to compression of her tuber sacrale (13 days post SI injections).
Differential Diagnoses (Ddx): T/L pain/discomfort; Ddx include saddle fit issues, referred pain from stifle issues, digestive issues. SI pain/discomfort; Ddx include previous injury, degenerative joint disease, referred stifle pain, local muscle pain. Right hind lameness; Ddx include IUFP, mild flattening of medial femoral condyle causing structural changes in the stifle joint, other. Possible temporomandibular joint (TMJ) pain; Ddx include dental issues, conformational or chiropractic problems in the poll area, local muscle pain. Minor issues with behavior during estrous cycles/frequent estrous cycles; Ddx include normal mare, cystic ovaries, granulosa cell tumor on ovary.
Medical Decision Making: Treating the T/L discomfort, SI pain and right stifle are important for improving Prix’s left lead canter performance and improving her chances of working up through the levels in dressage competition. Continuing to work on saddle fit is important to prevent recurrence of T/L issues. Prix has an appointment with a reputable saddle fitter this week. I recommended referral to an equine dentist to start the work up for possible TMJ pain. Continued core and hind limb strengthening exercises are important to help maintain back muscle comfort and to manage possible IUFP. Prix’s owner plans to finish the series of IRAP injections in her right stifle. Prix is needle shy, so I had to be careful of my needle numbers and locations. I was only able to place about 20 needles per session. She did better if her owner fed carrots and used her hand as a blinder behind her eyes so she couldn’t watch the needle placements. She was highly sensitive to any limb points, so I wasn’t able to needle many of these. I used massage for compensatory strain patterns and tight muscles/trigger points. Laser therapy would be great as well. I included a couple points to balance the autonomic nervous system, provide immune stimulation and hopefully relax the patient during treatment. I tried to include some points for abnormal estrous cycles, but only if they had dual purpose for the other issues I was treating.
Acupuncture Treatments: Prix was treated once weekly for 3 weeks, then again 2 weeks later (4 treatments). Central Nervous System Points: BL 20-23, BL 25-30; Peripheral Nervous System Points: ST 36; Autonomic Nervous System Points: LI 16, GV 14, Bai Hui, ST 36; Myofascial/Musculoskeletal Points: BL 20-23, BL 25-30, ST 36. Massage: All tense/tight muscles listed in the PE section above.
Outcomes/Discussion: Prix earned the best scores of their show history together after her first acupuncture treatment. The owner thinks her left lead canter is improving after each session. We plan to continue acupuncture treatments every 2-4 weeks as needed to further improve her comfort level and performance. Prix taught me to be careful of point location selection in order to minimize points but maximize results. I had to use very gentle needle placement techniques and distractions to get the needles in. Laser therapy would be great for her!
References: 1) Huisheng Xie, Patrick Colahan, Edgar A Ott: Evaluation of electroacupuncture treatment of horses with signs of chronic thoracolumbar pain; J Am Vet Med Assoc, July 2005;227(2):281-6. 2) Pedro V Michelotto, 2nd, Luis F C Bastos, Cristina S Sotomaior, Claudia T Pimpao: Acupuncture diagnosis in equine stifle disease; J Equine Vet Sci, August 2014;34(8):967-971.