Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2019012
Abstract:
Freija, a 9-year-old Friesian mare, presented for right hindlimb lameness and inability to maintain the canter, both noted after she was placed in training. A lameness exam localized the areas of discomfort to her right hock and back. Freija received four treatments consisting of dry needling over the course of two months. During this time, her trainer noted improvement in muscle tension and reported that Freija consistently held the canter on the lunge line and when ridden.
History/Chief Complaint:
Freija, a 9-year-old Friesian mare, was brought into training after having been unridden for 5 years. She had been started as a 3-year-old, remained in work for a year and a half and then, due to finances and time constraints, the owner stopped riding her. When Freija resumed work, the trainer noted immediately that her back appeared very tight and showed no movement when she was lunged. Also, any time she was asked for the canter, she would begin cross cantering or fall out of the canter to the trot. Freija was examined by her regular veterinarian, who found that she became more lame in the right hind after flexion tests. The owner declined both radiographs and hock joint injections, and Freija was started on 1g phenylbutazone twice daily with minimal improvement.
Physical Exam and Clinical Assessment:
Freija was bright, alert and interactive on presentation. She presented with a body condition score of 7/9. Heart rate, respiratory rate and temperature were within normal limits (WNL). Auscultation revealed normal heart and lung sounds with a normal sinus rhythm. Myofascial exam showed muscle tension over the back, with the epaxial musculature visibly and palpably firm extending from L2 – L7. Gait analysis revealed a grade 3/5 lameness in the right hind, with decreased hock flexion and decreased stride length. Distal limb flexion increased the lameness to 4/5. Hoof testers revealed no foot pain. Balance testing showed increased weight bearing in the forelimbs. Lateral bending of the neck in both directions was WNL. Freija was unable to flex her thoracolumbar spine, as evidenced by a lack of belly lift when stimulated. She was also unable to flex her LS joint when scratched over her hindquarters (cat scratch). There was no response to high velocity stimulation of the paraspinal muscles (flick) from T10/11 through L7, indicating marked myofascial restriction. Sacroiliac joint movement was found to be WNL. Hind limb rotation showed equal resistance and restriction to clockwise and counterclockwise rotation in both hind limbs. Cervical palpation and flexions were WNL. Freija’s mentation was appropriate, and cranial nerve function was WNL.
Freijawalkside12.11.19 Freijawalkaway12.11.19 Freijatrotside12.11.19 Freijatrotaway12.11.19
Problem List:
1. Grade 3-4/5 lameness in the right hindlimb
2. L2 – L7 epaxial muscle tension
3. Thoracolumbar myofascial restriction
4. Lumbosacral joint immobility
5. Restricted hindlimb movement through circular motion
6. Obesity
Differential Diagnosis:
1. Hindlimb lameness
–vascular: laminitis
–infectious/inflammatory: Lyme disease
–neoplastic: chondrosarcoma
–degenerative: osteoarthritis
–iatrogenic: increased workload
–congenital: osteochondrosis dessicans (OCD)
–autoimmune: immune mediated polyarthritis
–traumatic: kicked by another horse during turnout
–endocrine: polysaccharide storage myopathy
–myofascia: muscle strain
2. Epaxial muscle tension
–vascular: vasculitis
–infectious/inflammatory: myositis
–neoplastic: spinal tumor
–degenerative: over-riding dorsal spinal processes (kissing spine)
–iatrogenic: poor saddle fit
–congenital: poor conformation
–autoimmune: equine fibromyalgia syndrome
–traumatic: fall during turnout
–endocrine: hyperkalemic periodic paralysis
–myofascia: compensatory muscle tension
Putative Diagnosis:
Physical examination and history strongly suggest a diagnosis of osteoarthritis in the right hock joint with compensatory myofascial tension and restrictions to the lumbar epaxial muscles. The recent return to work is also a likely contributing factor to the myofascial restrictions.
Medical Decision Making:
My treatment choices were focused on providing pain relief to the right hock and reducing the myofascial tension and restrictions in the epaxial muscles. Dry needling was chosen for the treatments. Central point choices included: Bai Hui, BL 21, BL 23, BL 25, BL 27 and BL 28. Autonomic points used included: ST 36 and BL 40. Peripheral points used: ST 36, BL 40, and BL 60.
The trainer was left with instructions to perform 3 belly lifts, one cat scratch, and 10 hind limb circles both clockwise and counter clockwise daily before and after each training session.
Medical Acupuncture and Related Techniques Used:
Treatment 1, December 11, 2019
Seirin 0.20 x 30mm, 10 minutes
Bai Hui, BL 23, BL 25, BL 27, BL 28, BL 40, ST 36
Treatment 2, December 19, 2019
Seirin 0.20 x 30mm, 12 minutes
Bai Hui, BL 21, BL 23, BL 25, BL 27, BL 28, BL 40, ST 36
Treatment 3, January 6, 2020
Seirin 0.20 x 30mm, 10 minutes
Bai Hui, BL 21, BL 23, BL 27, BL 28, BL 40, ST 36
Treatment 4, January 19, 2020
Seirin 0.20 x 30mm, 13 minutes
Bai Hui, BL 21, BL 23, BL 27, BL 28, BL 40, BL 60
Freijatrotaway1.24.20 Freijatrotside1.24.20 Freijawalkaway1.24.20
Outcomes:
After the first treatment, the trainer noted that Freija’s stride length had improved with her hind foot landing in the front hoofprint. During the week after the second treatment, Freija was able to hold the canter on the lunge line without cross cantering or falling into the trot. At the time of the third treatment, it was noted on examination that Freija was now able to perform a small belly lift, and she showed less resistance to circling of the hind legs. During the fourth treatment, Freija’s lumbar epaxial muscles no longer appeared raised and were soft to the touch. Freija was also able to slightly flex her lumbosacral joint when a cat scratch was performed. She now is showing a grade 1/4 lameness in the right hind and is no longer receiving phenylbutazone.
Ideally, radiographs of the hocks should be evaluated to confirm the diagnosis of osteoarthritis. Additionally, nuclear scintigraphy (bone scan) would be beneficial in diagnosing bony changes to the spine as well as the hocks. However, based on the response to treatment, I feel that my management of the case was beneficial for the patient. I believe that Freija would have benefited from electroacupuncture to her lumbar region; however, it was unavailable at this time. Her owner and trainer plan that Freija will continue to receive acupuncture on a monthly basis or as needed for any acute flair ups of lameness.
References:
Xie H, Colahan P, OHEA. Evaluation of electroacupuncture treatment of horses with signs of chronic thoracolumbar pain. Journal of the American Veterinary Medical Association. 2005 Jul 15; 227 (2): 281-6.
Ross, M & Dyson, Sue. (2011). Diagnosis and management of lameness in the horse. 10.1016/C2009-0-50774-X
Riccio, B., Fraschetto, C., Villanueva, J., Cantatore, F. and Bertuglia, A. (2018). Two Multicenter Surveys on Equine Back-Pain 10 Years a Part. Frontiers in Veterinary