Written by a Medical Acupuncture for Veterinarians course graduate.  Signed release obtained from client/author. 4389

 

Abstract

Rio, a 13 year old Quarter horse gelding, was seen after previous lameness examinations by other veterinarians. The gelding has a history of a traumatic fall as a young horse and had bilateral forelimb lameness that initially improved with distal interphalangeal joint injections with corticosteroids. Repeated treatment was unsuccessful. The addition of acupuncture to a treatment regimen of therapeutic shoeing, veterinary chiropractic, veterinary acupuncture, and anti-inflammatory medications improved this horse’s comfort enough to trail ride when his owner had been considering euthanasia.

History and Presentation

Rio, a 13 year old Quarter horse gelding, was taken to a Veterinary Teaching Hospital by a previous owner in July 2012 for a lameness evaluation and complaint of stumbling that reportedly began after the gelding jumped a five-foot fence and fell. The lameness was isolated to the caudal third of both forefeet with regional nerve blocks. Radiographs showed mild changes to both navicular bones and a diagnosis of navicular syndrome/caudal heel pain was made. Both distal interphalangeal joints were treated with 8 mg triamcinolone, 250 mg amikacin, and hylartin V. Shoeing with a two degree wedge and a tapering isoxsuprine course was recommended. Rio reportedly improved after this treatment. The history between this evaluation and 2016 is unknown, and Rio was sold to the current owner. The current owner reported that both distal interphalangeal joints were injected again and that Opshos was administered in July 2016, but no improvement was noted. When Rio was first evaluated by in October 2016, he had a 3/5 lameness in the left forelimb and a 2/5 lameness in the right forelimb. A left hindlimb lameness was also observed on a circle. Chiropractic evaluation revealed withers offset to the left, a lack of movement in the neck, and pain upon flexion of the back. No abnormalities were found upon neurologic evaluation.

Physical Exam and Clinical Assessment

Upon initial evaluation in May 2017, Rio was bright, alert, and responsive, with a temperature of 99.6, heart rate of 36 beats per minute, and respiratory rate of 12 breaths per minute. The gelding preferred to walk on softer ground and was noticeably short-strided on gravel or concrete surfaces. At rest, Rio tended to stand with the left forelimb extended (“pointing”). The gelding was shod in front with plain shoes and leather wedge pads. On a baseline trot, Rio exhibited a left forelimb lameness and left hindlimb lameness. The overall quality of the trot was stilted and choppy.  Mildly elevated digital pulses were present in both forelimbs. Rio was reactive to palpation of the distal brachiocephalicus muscle bilaterally and was sensitive across the withers and topline. Poor muscling was present along the topline, especially over the withers. A large trigger point was palpable in both left and right triceps muscles.

Medical Decision Making

Knowledge of Rio’s history, previous treatments, and responses to these treatments made me optimistic that acupuncture might be able to provide another approach to pain management that could possibly break this cycle of chronic pain. I had the benefit of Rio’s medical records or direct observation of his response to equioxx, isoxsuprine, methocarbamol, gabapentin, joint injections with corticosteroids, bisphosphonates, therapeutic shoeing, and veterinary chiropractic treatments.  Acupuncture seemed a logical or even last resort in this case, as the owner was frustrated and considering euthanasia. I hoped that acupuncture would be able to relieve the long-standing compensatory muscle tension and trigger points.

Differential Diagnoses

Navicular syndrome/caudal heel pain, both forefeet; primary or compensatory left hindlimb lameness; cervical and/or thoracic vertebral osteoarthritis (without compression) secondary to traumatic fall; overriding dorsal spinous processes

Putative Diagnosis

Many of the differential diagnoses are still possible and may exist concurrently, but finances for diagnostics were limited. MRI of both forefeet would be valuable in assessing the soft tissue structures within the foot that are so frequently involved in lameness isolated to the foot. It is still unclear whether the forelimb lameness is the primary problem. However, the goal of adding acupuncture was to provide another approach to pain relief that would improve Rio’s every day quality of life.

 

Acupuncture Treatments

Three regular acupuncture treatments were completed, with the last two including electroacupuncture. After the first acupuncture treatment, a laser treatment of the acupuncture points was performed using a class IV laser. Rio was very amenable to all treatment sessions and exhibited signs of relaxation, including licking and chewing during treatment and sometimes in response to placement of particular needles. Treatment points included Bai Hui, GB 21, LU 1, SI 9, ST 36, SI 11, SI 12, LI 15, LI 16, TH 15, BL 54, BL 11/12/13/14, and BL 17/18/21/22. These points were selected based upon the myofascial examination and lameness history. In particular, the large trigger points in the triceps muscles at SI 9 were interesting to follow over the course of treatment as they responded to the “circle the dragon” approach and became less prominent and less painful to palpation. My hope was for acupuncture to relieve discomfort from his compensatory muscle and generalized body pain to augment the anti-inflammatory medications.

Outcome and Discussion

Since Rio boarded at the clinic from December-July 2017, it was easy to monitor daily comfort. Rio spent less time lying down, pointed the left forelimb less frequently, and was more assertive in interacting with the other geldings in pasture. These improvements were most noticeable after the addition of electroacupuncture. After these treatments, the owner was able to ride Rio on a short trail. Prior to this milestone, she had been considering euthanasia.

Rio’s case demonstrated the value of acupuncture for management of chronic pain that has been refractory to western treatments and diagnostics. More chronic lameness cases are generally more challenging to solve, so this case was a great example of incorporating acupuncture as an adjunctive approach to pain management. It was especially gratifying to watch Rio in the pasture interacting with the other geldings as any other horse would do. In this case, the addition of acupuncture provided Rio with an improved quality of life, allowing he and his owner to better enjoy each other.

References

Huisheng, X., et al. Influence of acupuncture on experimental lameness in horses. AAEP Proceedings 2001; 47: 347-357.

Schoen, A.M. Equine acupuncture: incorporation into lameness diagnosis and treatment. AAEP Proceedings 2000; 46: 80-83.

Shmalberg J., and X. Huisheng. The clinical applications of equine acupuncture. Journal of Equine Veterinary Science 2009; Vol 29, 8: 645-652.


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