Chronic Laminitis in a Friesian Cross Gelding

by Dr. Christina Mohos, Wellington Equine Services, Ontario, CANADA

Abstract:

Olaf with Dr. Christina Mohos

Dr. Mohos performing acupuncture on Olaf

A gelding with chronic laminitis in his left front (LF) foot experienced acute laminitis in his right front (RF) foot. The gelding had extreme difficulty walking, leaving the owner concerned about the gelding’s quality of life. The horse was treated with Veterinary Spinal Manipulation Therapy (VSMT), Acupuncture (AP), Electro-acupuncture (EAP) and massage. The outcome from the treatment program was a horse that was able to walk comfortably and was able to be weaned off pain medications. Demeanor and attitude improved, and the owners are happy to have another tool to help him live with chronic laminitis.

History and Presenting Complaints: Olaf is a 2013 Dutch Harness/Friesian gelding. He was purchased by his present owners in 2019 and they noticed an abnormal LF foot. Radiographs were taken of the LF foot in November 2019 and showed he had severe laminitis in the LF. At this point, Olaf’s front feet were shod with proper shoes and pads. Olaf was monitored closely, had his feet radiographed every 6 months and was started on 4cyte supplement. In August 2022, Olaf was observed to be very lame. Lameness score was 4/5 lame in both front legs. Radiographs were taken of Olaf’s front feet and there was rotation seen in the right front foot indicating laminitis. Olaf was started on phenylbutazone 1 gram orally twice daily, gabapentin 6.4g orally twice daily and acetaminophen 10g orally twice daily. VSMT was started with Olaf, and he was assessed biweekly. Olaf responded favorably to the VSMT and medications. In October 2022, Olaf had his blood tested to screen for Equine Metabolic Syndrome (EMS) or Pars Pituitary Intermedia Disease (PPID) which were within normal limits. 

Initial Exam: A brief physical exam was performed and was within normal limits. Lameness was 2/5 in the RF and 3/5 in the LF but also a hind end lameness was observed bilaterally. Olaf had difficulty walking on the concrete floor of the barn and was able to move easier on softer ground. It was difficult to pick up his front feet to ask him to bear weight on the opposing limb. Heat was palpated in the right front foot and the digital pulses were increased. He had a tucked pelvis with kyphosis in the lumbosacral area indicating pain in the lumbosacral region. Olaf also appeared to have a low head carriage which could indicate neck pain. 

Myofascial Evaluation: Olaf was able to extend his head ventrally when the left forelimb was extended but he was not able to do this on the right. He was able to circle his right hind leg but was unable to do circles with his left hind leg. Lateral neck flexion was reduced bilaterally at the level of cervical vertebrae 3 (C3). Olaf was found to have multiple trigger points especially in the cervical region. He was found to have a tight, hot and painful longissimus dorsi muscle with myofascial restriction from thoracic vertebra 15 (T15) to the sacrum. The sacral area was very painful to palpate and there was no mobility in the sacroiliac joint (SI) when the tuber sacrale were compressed. The lumbosacral joint also had reduced movement. High velocity dorsal rami stimulation was painful bilaterally and there was a reduced reaction. 

Neurological Assessment: Cranial nerves were intact, and his mentation was normal. Olaf was able to back up normally. He was able to normally cross his hind legs over each other and he had a normal tail pull test. Olaf could walk normally when his head was lifted. No neurological abnormalities were observed.

Problem List:

  1. Lameness in the front feet
  2. Pain in the lumbosacral/pelvic region
  3. Neck pain
  4. Back pain

Differential Diagnosis for Lameness in front feet:

V – Vasculitis, Laminitis; I – Septicemia; N – Osteosarcoma in cervical vertebrae, lymphoma; D – Osteoarthritis in cervical vertebrae or front limbs (pastern, fetlock, carpus, elbow or shoulder joints); I – Possible previous neurectomy and the recurrence of a neuroma, or joint injection that caused damage to the joint cartilage, C- Cervical malformation/dysplasia, bilateral navicular disease, osteochondrosis dissecans; A – Fibromyalgia; T – Fracture of pedal bones or navicular bones, fracture in cervical vertebrae; E – Equine Metabolic Syndrome, PPID – secondary laminitis; Myofascia – Compensatory changes and trigger points in neck and forelimb muscle.

Differential Diagnosis for Lumbosacral/pelvic pain:

V – Saddle thrombosis, vasculitis; I – Fibrotic myopathy, septic arthritis of sacrum or pelvis; N – Osteosarcoma of sacrum or pelvis; D – Osteoarthritis in sacroiliac joint; I – Possible previous sacroiliac injection; C – Osteochondrosis dissecans in hind limbs; A – Fibromyalgia; T – Impact injury to SI, repetitive motion injury in hind limbs leading to SI osteoarthritis; E – PPID – Laminitis with all hoof involvement; Myofascia – Compensation in the hind end from overuse due to pain in front feet.

Definitive Diagnosis: Chronic lameness in front feet is caused by laminitis as based on radiographs.  Laminitis is most likely due to mechanical breakdown from overweighting the RF. We have ruled out endocrine causes for the laminitis. The diagnosis for the lumbosacral/pelvic issue is most likely compensatory and strongly indicative of sacroiliac pain. Further imaging could include a nuclear scintigraphy scan to assess the pelvic region including the SI joints. 

Medical Decision Making/Plan:  I decided to treat Olaf every 2 weeks and introduced EAP after his first session. Baihui and the Bladder line would be a key points to treat the lumbosacral area and pain in the longissimus dorsi muscle based on palpation. GV 4 and GV 14 were placed as central points to treat lumbar pain and cervical/forelimb pain respectively. To treat pain in the lumbosacral area, I placed BL 25 and BL 27 bilaterally at each session. I used EAP from BL 25 to BL 27 at every session to help with sacroiliac pain. BL 27 was also a good point to stimulate the parasympathetic system. I wanted to focus on points that would help with the pain from the laminitis primarily as I thought that the laminitis was causing the compensatory pain in the neck, pelvis and back. I selected points LI 1, LU 11, SI 1, HT 9 on both front feet to treat laminitic pain as distal points1. These points covered both the median and ulnar nerves but also impacted the nervi vasorum which should encourage vasodilation in the feet. I selected LI 15 and TH 14 bilaterally to treat any shoulder pain via the suprascapular nerve and axillary nerve as it can be due to pain in front feet. I used LI 11 on the front legs to target the radial nerve and for its anti-inflammatory properties. PC 6 was selected to target the median nerve and for its connection to the nucleus tractus solitarius (NTS), trying to encourage homeostasis in the body. VSMT was continued with Olaf as he would continue to get a pelvic asymmetry early in the sessions. Massage was used to try and loosen tight muscles prior to placing needles and based on palpation (petrissage and effleurage).

Acupuncture Treatments:

October 26, 2022. Needles: Seiren J type 0.25 x 30mm (purple). Acupuncture Points: Bilateral: Baihui, GV 4, GV 14, BL 21, BL 22, BL 25, GB 21, LI 1, LU 11, SI 1, HT 9 Left: ST 10, BL 11, BL 12, Bl 13, SI 11, SI 12.  Myofascial exam: BL 11, GB 21, SI 11, and SI 12 (left). Olaf was initially restless before treatment. Olaf settled about 10 minutes after the central points were placed. I noticed that Olaf was very tight in the lumbosacral area and there was a lot of muscle grab due to muscle tension in this area (BL 25). I was nervous to place more needles in the area, so I placed needles proximally at BL 21, and BL 22 bilaterally. BL 11, BL 12, BL 13 were used on the left for neck pain that could be addressed at the cervicothoracic nerve roots and associated left front lameness. GB 21 was used because it was a trigger point (TP) on the right and to treat thoracic limb lameness that may be originating from the neck and spinal accessory nerve. ST 10 was palpated sore, most likely because of lameness in the front left leg as it was on the left. Olaf was massaged using petrissage followed by effleurage after the session. Muscles around the pelvis were relaxing but still painful to deep palpation. 

November 1, 2022.  Needles: Seiren J Type 0.25 x 30mm (purple); Acupuncture Points: Bilateral: Baihui, GV 4, GV 14, BL 11, BL 12, BL 13, BL 25, BL 27, BL 40, BL 54, LI 15, TH 14, LI 1, LU 11, SI 1, HT 9, LI 11, PC 6, GB 30, GB 21. Left Electroacupuncture (EAP): Ito unit- 4Hz, 5 minutes per area; BL 25-27, LI1 – LU 11, SI 1–HT 9. Right Electroacupuncture: Ito unit- 4Hz, 5 minutes per area; BL 25-27, LI 1- LU 11, SI 1- HT 9. Myofascial Exam: TP right biceps femoris muscle. Left TPs: BL 40, BL 54, GB 30, triceps muscle.  Owner has reported that Olaf is already feeling more comfortable. They note he can navigate the concrete floor in the barn more easily and is not lying down as frequently as he had been. Today I placed BL 25 and BL 27 bilaterally so that I could perform EAP on the area. EAP was also attempted on the distal limb points. BL 40 was a trigger point on the left and used also for pelvic limb pain via tibial nerve. BL 54 was used for hip and gluteal pain and to impact the sciatic nerve. GB 30 was selected for sciatic pain and hip pain. After this session, the muscles in the pelvic area were relaxed and no longer painful.

November 23, 2022. Needles:  Seiren 0.25 x 0.30mm (purple). Myofascial Exam: Bilateral: TP BL 10, BL 11,BL 12, BL 13, BL 14, BL15 Right: GB 21, cranial brachiocephalicus muscle around the second cervical vertebrae Left: TP LI 15, TH 14. Acupuncture points: Baihui, GV 4, GV 14, BL 10, BL 11, BL 12, BL 13, BL 14, BL 15, BL 25, BL 27, BL 40, BL 54, GB 30, LI 1, LU 11, SI 1, HT 9, LI 11, PC 6, ST 36, KI 1 Left: LI 15, TH 14, Right: GB 21. Electroacupuncture left: Ito unit 4 Hz, 5 minutes per area: LI 1-LU 11, SI 1- HT 9, BL 25-27. Electroacupuncture right: Ito unit 4 Hz, 5 minutes per area; SI 1-HT 9, LI 1-LU 11, BL 25-BL 27. At this session, sacroiliac discomfort was reassessed. Olaf was able to flex his neck ventrally when the front leg was extended on both sides. Hind leg circling was also assessed, and Olaf was found to be within normal limits. BL 10 was palpated as a TP so I selected this point to aid with cervical pain that may be originating from the cranial cervical spinal nerves. Today I used ST 36 bilaterally as a point for stifle pain and also for its anti-inflammatory properties. 

Outcome:My goal with Olaf was to provide enough analgesia with AP to make him comfortable enough to live at pasture. Prior to AP, Olaf was depressed and reactive. This changed after the initial session, Olaf loved his treatments and would fall asleep. Interestingly, the initial foot points were no problem for Olaf but at the last session even the needle insertion was stimulating so I have stopped electroacupuncture on his feet. I get the impression of improved sensation or vascularization in the feet which indicates an improvement in function due to acupuncture.  There is some anecdotal evidence that AP can improve lameness and reduces pain in laminitic horses, but additional research is warranted especially considering that the majority of laminitic horses are euthanized3. Further research in this area could include serial venograms done in laminitic patients before and after AP. Pain in the sacroiliac region was compensatory from his altered gait due to laminitis and this improved greatly with AP and EAP1. Posture and neck pain has improved as has his left front lameness.

The owners have said they are very happy because Olaf does not lay down all the time anymore and is happy to go out with his friends. He does still have a bit of difficulty in the barn on hard ground, but this is a huge improvement in a horse that could not walk at all in the barn prior to acupuncture.  Pain control in laminitic horses is critical to their outcome3. Long-term NSAID medication is an ongoing concern with the horse and we were able to successfully wean him off phenylbutazone and acetaminophen after starting acupuncture. I plan to maintain his acupuncture sessions monthly as he seems to be remaining comfortable with that schedule.

References:

  1. Lancaster LS, Bowker RM. Acupuncture Points of the Horse’s Distal Thoracic Limb: A Neuroanatomic Approach to the Transposition of Traditional Points. Animals (Basel). 2012 Sep 17;2(3):455-71. doi: 10.3390/ani2030455. PMID: 26487033; PMCID: PMC4494290.
  2. Lee D, May K, Faramarzi B. Comparison of first and second acupuncture treatments in horses with chronic laminitis. Iran J Vet Res. 2019 Winter;20(1):9-12. PMID: 31191693; PMCID: PMC6509908.
  3. Faramarzi B, Lee D, May K, Dong F. Response to acupuncture treatment in horses with chronic laminitis. Can Vet J. 2017 Aug;58(8):823-827. PMID: 28761187; PMCID: PMC5508962.