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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/5940.

Abstract

The subject of this case report is an approximately three-year-old old female spayed pointer/boxer mix that is treated for a suspect left stifle injury. The origin of her stifle injury is unknown, but is attributed to an event where the subject jumped on the couch, yelped, and became non-weight bearing on the left hindlimb. A total of six acupuncture treatments were performed over the course of three weeks.

The patient’s myofascial exam has subjectively improved her left sartorius muscle (is not as taut and ropey), she does not react to her iliopsoas being palpated, and her trigger points in the lumbosacral region are not as easily stimulated. The patient’s gait appears to have improved, but this could be due to the angling of the video before and after treatment.  The patient does not hold her left limb as lateral in the sit position as she did prior to treatment.

History Presentation

Sophie presents with a suspect left stifle injury that waxes and wanes with periods of intense exercise. Her suspect left stifle injury can be attributed to an event about six months ago when Sophie jumped on the couch and let out a yelp and began trembling. She was then non-weight bearing on the left hindlimb for about 30 minutes and expressed pain when the stifle was touched. Since this incident, she externally rotates and abducts the left hindlimb during her gait, and this is more exaggerated after playing Frisbee or going on long runs. Sophie was adopted from her owner at about 10 weeks old and had an unknown origin of previous trauma that presented as a scar over her lumbosacral region.  Radiographs at about six months of age revealed a healed malunion fracture of the right proximal femur, a previous fracture of the right acetabular bone vs congenital change, a transitional vertebrae vs previous fracture at L-7 through S-1 and lumbosacral kyphosis.

Physical Examination and Clinical Assessments

On April 20, 2016, Sophie is bright, alert, responsive with a heart rate of 80bpm and a respiratory rate of 20bpm. A temperature was not taken.  She is well muscled with a BCS of 5/9. The patient has a respiratory sinus arrhythmia with strong and synchronous femoral pulses. She has mild dental tartar present on her upper and lower canines, premolars, and molars. Over her dorsal lumbosacral region, just left to midline, there is a 5 x 2 cm scar with underlying scar tissue. All other aspects of her physical exam are normal. The neurological exam was within normal limits. There is good range of motion in all joints. The patient becomes nervous when the left stifle is flexed and the left hip is extended. No cranial drawer is appreciated. When walking, she externally rotates and abducts her left hindlimb. In her sit position, her left leg is more lateral than her right and externally rotated.

Myofascial exam – A few taut bands were present in the right side of the neck, associated with the omotransversarius muscle.  Her iliopsoas muscle palpates tight bilaterally and the patient reacts to moderate palpation. Trigger points are present in the lumbosacral region bilaterally. Her left sartorius muscle is tight and ropey. There is heat present over her left adductors.

Medical Decision Making

Points along the stomach channel were chosen to address the pelvic limb extensors and specifically affect proprioception of the knee and ligamentous hypermobility. ST-34 was used to stimulate golgi tendon organs to relax the vastus lateralis muscle. ST-36 was chosen to stimulate nervi vasorum and improve circulation to the knee. Points along the bladder line where chosen for their relation to the sciatic nerve.  BL-36 was specifically chosen later on for its association with the semimembranosus and semitendinosus. This point targets the motor function to the hamstrings and caudal thigh muscles. BL-54 was used as a master point for the hindlimb and to target the ilipsoas muscle. Local points were used to address the suspected left stifle injury and lumbosacral trigger points. The contralateral side to her injury was used as well for cross-talk between the nerves.

Acupuncture Treatment

With Sophie’s history of a potential injury to her left stifle, treatment was chosen to address a left stifle injury. The patient’s previous traumatic event that occurred sometime before the age of 10 weeks old that fractured her right femur and caused a distortion to her L-7 through S-1 region was kept in consideration when developing a treatment plan. Dry needling was performed twice per week for three weeks. A total of six treatments were performed. Sophie occasionally did some stretching and strengthening on a peanut throughout her treatment (iliopsoas stretching, core strengthening, and hamstring strengthening).

4/20/2016: Treatment consisted of dry needling at SP-9, SP-10, ST-34, ST-36 (all on the left), BL-23 (right and left), GV-14, and Bai Hui

4/22/2016: Treatment consisted of dry needling at SP-9, SP-10, ST-34, ST-36 (all on the left), BL-23 (right and left), GV-14, and Bai Hui

4/26/2016: Treatment consisted of dry needling at ST-34, ST-36, GB-34, BL-54, GB-29, GB-30 (all on the right), SP-9 and SP-10 (on the left), BL-23 (right and left), GV-14, and Bai Hui

4/29/2016: Treatment consisted of dry needling at ST-34, ST-36, GB-34, BL-36, BL-54, GB-29, GB-30 (all on the left), BL-23 (right and left), GV-14, and Bai Hui

5/2/2016: Treatment consisted of dry needling at ST-34, ST-36, GB-34, GB-29, GB-30, BL-54, BL-36, SI-9 (all on the right), SP-9 (on the left), BL-23 (right and left), Bai Hui, and GV-14

5/4/2016: Treatment consisted of dry needling at ST-34, ST-36, GB-34, GB-29, GB-30, BL-54, BL-36, SI-19 (all on the left), BL-25 (right and left), GV-14, and Bai Hui


Outcomes and Discussions
Before and after gait analysis, the patient’s sit conformation, and before and after myofascial exams were used to analyze the patient’s progress over the three-week treatment. The patient’s myofascial exam has subjectively improved- her left sartorius muscle is not as taut and ropey, she does not react to her iliopsoas being palpated, and her trigger points in the lumbosacral region are not as easily stimulated. The patient’s gait appears to have improved, but this could be due to the angling of the video before and after treatment. The patient does not hold her left limb as lateral in the sit position as she did prior to treatment. The patient needs therapeutic exercise on a regular basis to completely improve her gait by strengthening the muscles that support the stifle. The use of the peanut for strengthening was only used once a week for ten minutes. A more regular therapeutic exercise targeted at strengthening the knee stabilizers and core would most likely improve her gait.

I learned that acupuncture is an excellent modality to help with osteoarthritis symptoms including pain, but that it is not always successful when used alone. Combinations with therapeutic exercise would be beneficial for this patient. In a review study of 61 cases, it was found that acupuncture helped improve pain, local stiffness, and inflammation in osteoarthritis (especially in patients with hip, stifle, and/or shoulder osteoarthritis). This article discusses how the majority of trigger points that develop with osteoarthritis correlated with acupuncture points and discussed how acupuncture can act as a regulator of alpha and gamma motor neuron activity to reduce joint swelling, pain, and inflammation (Janssens, 1986).

Reference
JANSSENS, L. A. A. (1986), Observations on acupuncture therapy of chronic osteoarthritis in dogs: a review of sixty-one cases. Journal of Small Animal Practice, 27: 825–837.

doi: 10.1111/j.1748-5827.1986.tb02247