Written by a Medical Acupuncture for Veterinarians course graduate.  Signed release obtained from client/author. A2017043

Abstract: Precious, a 12-year-old Welsh pony mare, with an acute Grade 3/5 right hind
lameness and marked right tibiotarsal joint effusion. Precious had a history of recent injection of
the tibiotarsal joints with hyaluronic acid and corticosteroids. She was eventually diagnosed
with focal osteomyelitis of the talus and distal tibia. Following arthroscopic debridment of the
infected bone, Precious underwent an extensive recovery with prolonged Grade 4/5 lameness of
the right hind limb. Precious was treated with acupuncture for pain management and
prophylactic treatment supporting limb in case of laminitis.

History and Presentation: Precious presented with an acute Grade 3/5 right hind lameness and
marked right tibiotarsal joint effusion approximately 2 weeks after joint injection with hyaluronic
acid and corticosteroids. Radiographs of the right tarsus and joint fluid analysis from the tarsal
joints were unremarkable. Precious was referred for nuclear scintigraphy, which showed severe
focal isotope uptake in the right talus consistent with a stress fracture. She was sent home on
strict rest and anti-inflammatories. At the 30 day recheck, Precious presented to me Grade 4/5
lame right hind with increased effusion of the right tibiotarsal joint. At that time, joint fluid
analysis was consistent with a joint infection (white cell count>25,000, SAA >3,000).
Arthroscopic debridement of the infected bone was performed and she was treated with systemic
and intra-articular antibiotics. Precious continued to be Grade 4/5 lame right hind even after the
infection resolved.

Physical Examination and Clinical Assessments: Physical exam was unremarkable on
presentation with the exception of the marked right tibiotarsal joint effusion and Grade 4/5 right
hind lameness. The joint fluid analysis and systemic indicators of infection were within normal
limits following prolong systemic and local antibiotic treatment. She had moderate diffuse
muscle atrophy with marked atrophy of the right gluteals. Her digital pulses were within normal
limits. She had significant myofascial tie-down over her epaxial muscles and gluteals. She was
extremely reactive over “hocks points” including BL18 and BL40. She also had mild sensitivity
on the points corresponding to the stomach and large intestines.

Medical Decision Making: Precious’s pain was not well managed medically. She received
some relief from non-steroidal anti-inflammatory medications but was a risk for gastrointestinal
ulcers from prolonged NSAID treatment. She was also at risk for colitis due to the prolonged
antibiotic therapy needed to resolve her osteomyelitis. At the time of presentation, the biggest
concern was support limb laminitis in her left hind leg because she had been non-weight bearing
in her right hind leg for almost 6 weeks.
Precious’s acupuncture treatments targeted the large muscles groups effected by her inability to
bear weight on the right hind leg, her right hock, gastrointestinal support, and increasing
bloodflow to her left hind foot to prevent support limb laminitis.

Differential Diagnoses: Septic arthritis of the tibiotarsal joint

Definitive (or Putative) Diagnosis (or Diagnoses): Focal osteomyelitis of the right talus and
tibia and septic arthritis of the tibiotarsal joint diagnosed by arthroscopy

Acupuncture Treatments: Precious was treated with electro-acupuncture 3 times a week for 2
weeks, then weekly. She is still undergoing acupuncture treatment for pain management. Her
treatment protocol consists of the following points:
• Epaxial and gluteal myofascial “tie-down”/pain: GB24, LR14, ST10, BL25, BL27, BL28,
BL40
• Gastrointestinal support: BL20, BL21, ST36
• Right tarsus (treatment was bilateral): GB27, BL18, BL35, BL39
• Left hind foot (treatment was bilateral): Ting points, SP9
• Additional points: Bai Hui, LI16

Outcomes, Discussions, and References: Precious continues to improve and has not had any
setbacks despite her prolonged lameness. Her current tight hind lameness is a Grade 2/5. She is
gradually increasing exercise, including turnout in a small medical paddock, with hope of one
day being a broodmare. Her muscle tone improves with each treatment and her attitude and
appetite remain good. Acupuncture has offered an excellent adjunct to traditional pain
management for her and has provided her increased comfort in her prolonged recovery.


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