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Written by a Medical Acupuncture for Veterinarians Course Graduate. Author’s name available upon request. Signed release obtained from client/author.

Abstract

A five-year-old neutered Australian shepherd had right TPLO surgery four months ago.  Acupuncture and massage have been of benefit for the compensatory muscle strain of the forelimbs and back. Acupuncture was used with the goals of increasing joint stability and decreasing pain associated with the patellar tendonitis, a common TPLO post-operative complication.

History Presentation

Bullitt had TPLO surgery on his right stifle four months prior to evaluation. Post-operative complications included severe tendonitis of the straight patellar tendon, significant muscle atrophy of the gluteal and adductor muscles, and lack of stability of the stifle with a tendency to have poor proprioception and lack of ability to prevent inappropriate abduction of the limb when sitting and walking on slippery surfaces.  Adequan has been administered every two weeks and deramaxx administered as needed. Cryotherapy is used as needed for the tendonitis.

Physical Examination and Clinical Assessments

At this time, Bullitt has mild atrophy of the right gluteal muscles and right adductor muscles. Bullitt has palpable thickening and pain of the straight patellar tendon, intermittent lameness, and poor ability to control his leg from abducting irregularly when sitting or walking on a smooth surface. Myofascial abnormalities are present in the pectoral muscles, ventral neck musculature, triceps muscles, and rhomboideus muscles. Trigger points are present in the rhomboideus muscles and pectorals. Bullitt is in good health otherwise with a non-remarkable physical exam.

Medical Decision Making

My goals for Bullitt have been to regain as much proprioception and muscle tone of the affected limb and mitigate the compensatory strain of the forelimbs and opposite hindlimb. Controlled activity and swimming have been used to increase muscle tone. Pain has been managed by cryotherapy and derramax as needed. Adequan has been used to support overall cartilage health. Balance exercises have been added to help Bullitt regain his proprioception. Massage has been used to treat the compensatory strain in the pectoral, ventral neck, and triceps musculature. Massage was chosen instead of acupuncture for these areas due to Bullitt’s fast little nose that would likely snatch a needle from these locations. Acupuncture was used to treat the Rhomboideus muscle trigger points. Acupuncture points to increase proprioception of the stifle joint and support the pes anserine, which is damaged during the TPLO procedure, were chosen. Acupuncture points for stifle pain were chosen, as well. Other goals of the acupuncture treatments were to decrease stifle inflammation and patellar tendonitis.

Acupuncture Treatment

GV-20 .16mm by 15 mm needle for a calming effect provided by Trigeminal nerve feedback to the nucleus tractus solitarius to create increased parasympathetic tone.  Also used to treat the cervical tension by neuromodulation of the cranial cervical spinal nerves.

GV-14 .20mm by 30mm needle to utilize the cervicothoracic spinal nerves to treat the cervical and rhomboideus muscle strain.

BL-12, BL-13, BL-14  .15mm by 15mm needles to treat the rhomboideus muscle spasm via neuromodulation of the cervicothoracic spinal nerves (BL-12) and cranial thoracic spinal nerves (BL-13, BL-14.)

ST-36 was used to provide parasympathetic support via the fibular nerve though its feedback to the nucleus tractus solitarius. Also local input for the stifle joint and cranial tibias, which is at the level of the inappropriate sized screw that is extending beyond the bone cortex into the soft tissue. 0.20mm by 30 mm needles

ST-34 was used for stifle pain and treatment of the quadriceps muscles on the lateral thigh through neuromodulation via the femoral nerve. I was hoping this point would aid in decreasing the tension of the quadriceps on the patellar tendon. 0.20mm by 30 mm needles.

SP-10 was used for stifle pain and effects on the quadriceps of the medial thigh via neuromodulation of the femoral nerve. I was hoping this point would aid in decreasing the tension of the quadriceps on the patellar tendon. 0.20mm by 30 mm needles.

SP-9 was used for support of stifle pain and to stimulate the region close to the pes anserine for increased proprioception via neuromodulation along the saphenous and tibia nerves. I was hoping this point would benefit proprioception as well as the development of the adductor muscles. 0.20mm by 30 mm needles.

GB-34 used to treat stifle pain and muscular tension through neuromodulation of the fibular nerve. This point was also chosen for its proximity to the surgical site and region of the inappropriate hardware.

All of these points were dry needled and left in for 15 to 20 minutes. All bilaterally available points were as such. I have concerns about Bullitt’s left stifle holding up to the added strain, so the same points were used to support it as were used to treat the right stifle.

Three weeks after the first treatment, Bullitt’s second treatment included points GV-20, GV-14, BL 16-18 (where he had some myofascial strain patterns,) SP-9, SP-10, ST-34, ST-36, GB-34, GB-33. Needle size of .16 mm by 15mm where used for GV-20 and BL16-18. Needle size of 0.20mm by 30 mm where used for the other points during Bullitt’s second treatment.

My considerations for further treatments include treating points to help the gluteal muscle atrophy. These points include the hip triad of BL-54 (sciatic n.) GB-29 (cranial gluteal n.) and GB-30 (sciatic n.). Additional points I may use to treat the stifle during future visits are LR-8 (saphenous and tibial nerves) to provide stimulation to the region of the pes anserine and adductor muscles, Xyian (for patellar tendonitis), GB-33 (Fibular n.), and GB-31 (sciatic and femoral nn.).

Outcomes and Discussions

Given the multi-modality rehabilitation of Bullitt, it will be difficult to objectively determine the specific and quantitative benefit of acupuncture. The trigger points and muscle tension in the rhomboideus muscles where notably improved and the muscles were softer after the treatment. Bullitt did become quite relaxed a few minutes after having a needle placed at GV-20. Bullitt was slightly less lame after his treatment, however the lameness is not consistent enough to have a definitive assessment of before and after treatment. Bullitt had no adverse events from the treatments. Bullitt’s ability to control his limb from inappropriate abduction was improved at the time of the second treatment. Acupuncture has increased the proprioception of human athletes with functional ankle instability (2) and increased the outcomes of supraspinatus tendinitis rehabilitation in humans(1).

References:

1.)  “A Randomized controlled trails on the effects of acupuncture and proprioceptive neuromuscular facilitation on supraspinatus tendinitis” ( Sokunbi, OG; Muhwhati, L; Robinson, P) IOSR Journal of Dental and Medical Sciences Vol 13, issue 11. PP63-69. Nov. 2014.

 

2.)  “Effects of electroacupuncture on the proprioception of athletes with functional ankle instability” (Yan ZHU, et. al) World Journal of acupuncture moxibustion, volume 23, Issue 1, PP 4-8. January 2013.