Author: Dr. Patricia Khor 

Written in 2018 for the Case Report Requirement for Medical Acupuncture for Veterinarians Certification

Abstract “Trixie” had an acute non-weight bearing lameness of the left hind leg after running i:n the backyard.  Under sedation, she was palpated and radiographs were performed.  She was diagnosed with cruciate ligament tear of the left stifle, hip dysplasia of the right coxofemoral joint and osteoarthritis of the right stifle, where she had previous surgical fixation of a cruciate ligament injury.  She was treated with multimodal approach of acupuncture, photomedicine, bracing, oral pain control and joint protectants.  After two months of treatment, she has demonstrated progressive improvements and is now consistently weight bearing on the affected left hind leg.

History and Presentation: “Trixie” is an 8-year-old female-spayed, West Highland Terrier mix breed.  Her past medical history included a cruciate ligament injury to her right stifle during which a partial medial meniscectomy, extracapsular suture stabilization with Fiberwire was performed by a board-certified veterinary surgeon.  The recovery was longer than expected and she required rehabilitation for 3-4 months before she was able to go back to regular activity.  Approximately a year after the surgical repair, the owner noted that “Trixie” would occasionally lick at the right stifle and appeared stiff after she had been lying down for an extended amount of time.  Presumptive osteoarthritis was diagnosed, and joint supplements were recommended to include glucosamine hydrochloride, chondroitin sulfate and avocado/soybean unsaponifiables (Dasuquin), omega fatty acids through Hill’s prescription j/d and pentosan polysulfate sodium injections (Cartrophen Vet).  She was also prescribed gabapentin and robenocoxib (Onsior). 

On October 10, 2018, “Trixie” was presented for acute lameness of the left hind leg after being let out into the backyard that same morning.  She was unsupervised outdoors and had been known to run along the fence chasing after the neighbour’s dog.  She returned to the home with a non-weight bearing lameness of the left hind leg.  Owner did not note any other concerns.

Physical Examination & Clinical Assessments: On examination, “Trixie” was bright, alert and responsive.  Her weight was 7.8kg with a body condition score of 6/9, according to the World Small Animal Veterinary Association scale.  She was slightly nervous through the physical examination.  Her temperature, heart rate and respiratory rate were within normal limits.  Chest auscultation was normal.  She was slightly tense on abdominal palpation.  Peripheral lymph node palpation were normal. 

She was non-weight bearing on the left hind leg but would occasionally toe-touch when standing still.  Her weight was shifted to the right hind leg and her head carriage was slightly low.  There was no ataxia and conscious proprioception were normal on all four limbs.  Her longissimus muscles were tense on palpation around the lumbar spine with some trigger points noted.  Palpation of the left hind leg showed mild tension on the hamstring muscles (biceps femoris, semimembranosus and semitendinosus) and quadricep femoris muscles (rectus femoris, vastus lateralis, vastus intermedius, vastus medialis).  She resisted full extension of the left coxofemoral joint. She was moderately painful on gentle palpation of the left stifle; and was significantly more uncomfortable on extension of the stifle.  There was no meniscal click, but mild joint effusion was noted on palpation of the left stifle.  Minimal drawer sign and tibial thrust were noted from that stifle.  The left tarsus and digits palpated normally.  Patella and withdrawal reflexes were within normal limits. Cross-extensor reflex was normal.

Palpation of the right hind leg showed moderate tension on the hamstrings, quadriceps, and gluteal muscle groups.  “Trixie” resisted full extension of the right hip, she had good range of motion on the stifle with mild crepitus.  There was no drawer sign or tibial thrust on that stifle. Her right carpus & digits were normal on palpation.  Patella and withdrawal reflexes were normal.  Cross-extensor reflex was normal.

Radiographs were taken, under sedation.  The pelvis appeared normal.  The right acetabulum covers less than 50% of the right femoral head of the femur.  The neck of the femur was thickened.  There was remodelling and flattening of the femoral head.  The left hip was normal.  Lateral and anterior-posterior views of both stifles were taken.  There was a bone screw noted on the latero-distal femur of the right stifle from previous cruciate surgery.  Some osteophytes were noted in the right stifle joint.  The left stifle appears to have mild joint effusion.  There were no evidence of osteophytes in the joint or bone fractures.  The drawer test was conducted again, while “Trixie” was under sedation.  This time, the drawer test was positive on the left stifle. 

Problem List:  “Trixie’s” problem list included acute pain and lameness of the left stifle, Grade II/IV hip dysplasia on the right side, previous extracapsular repair and osteoarthritis of the right stifle and lower back pain. 

Differential diagnoses for the lameness of the left hind leg and hip disease included thrombosis/vascular accident, vector-borne infection causing joint pain, neoplasia of the bone or soft tissue at the level of the joint or spine, degenerative joint disease or osteoarthritis, poor biomechanics secondary to poor genetics, systemic lupus erythematosus, immune-mediated polyarthritis, radiculopathy, intervertebral disc disease, trauma to the left leg or spine, endocrine disease such as hypothyroidism or hyperadrenocorticism causing weight gain and resulting increase in stress on the joints. 

Definitive diagnoses were obtained after a positive drawer sign during palpation of the left stifle, which confirmed cruciate ligament instability or tear.  Since “Trixie” did not show signs of neurological deficits, it was less likely that the acute lameness was secondary to significant spinal cord disease.  The imaging studies helped confirm the presence of hip dysplasia as well as inflammation within the left stifle joint. 

Medical decision making: “Trixie’s” pain management and return to normal gait were my primary goals.  Her owners had been through a discussion about cruciate ligament injury in the past for her right stifle and assumed that surgery was the only option for Trixie.  I presented to them another option of medical management through integrative care which included acupuncture, photomedicine, oral supplements and pain control.  “Trixie’s” owners expressed that there were challenges post-operatively from her previous cruciate surgery so they elected to try integrative care and medical management for the left stifle. 

My goal for pain control through acupuncture was to neuromodulate the body to blunt the perception of pain, especially from the injured leg and to encourage release of endogenous opioids.  I wanted to improve the stability of the stifles by improved strength of the hamstrings, quadriceps and gastrocnemius muscles.  My acupuncture points were selected based on “Trixie’s” trigger points as well as specific points to target the central nervous system (CNS), peripheral nervous system (PNS) and autonomic nervous system (ANS).  Most of these chosen points remained consistent throughout her series of treatments.  I would adjust the points based on my myofascial palpation at each visit.  “Trixie” was treated with acupuncture (and electroacupuncture) and photomedicine every 1-2 weeks.  In addition, she was continued on joint supplements as previously noted.  She was re-started on robenacoxib (Onsior) every 24hours and gabapentin every 8-12hours.  No leash-free running, jumping or use of stairs were emphasized.

Medical acupuncture and related techniques used

October 10, 2018: “Trixie” was still sedated from radiology so I was able to needle more points than I would normally on a patient receiving her 1st treatment.  Acupuncture was done with Seirin 0.16 X 15mm at GV 20, GV 14 and Bai Hui (CNS and ANS stimulation).  Bilateral BL 23, BL 25 (CNS and PNS). Left and right hip treated at BL 54, GB 29, GB 30 (CNS and PNS).  The left stifle was treated at ST 36 (ANS & PNS), ST 34, SP 10, SP 9, BL 60 (PNS).  The right leg was treated at KI 3 (PNS).  Photomedicine with Class IV Companion laser was performed on the left stifle and right hip.

October 23, 2018

“Trixie” was toe-touching on the left hind leg and was kyphotic along spinal vertebrae T8 to L3 region, with trigger points bilaterally.  The area was warm to touch. There was muscle atrophy on her left hind quadricep & hamstring muscles. The right hind leg had hypertonic hamstring and quadricep muscles.  Acupuncture was done with Seirin 0.16 X 15mm at GV 20.  The left stifle was treated at ST 34 and ST 36.  The right hind was treated at SP 10.  Carbo 0.18 X 13mm were used at bladder points bilaterally at BL 20, BL 21, BL 23 and BL 25.  Electroacupuncture was delivered by Pantheon electrostimulator 8c. Pro; with clips attached to needles along the bladder channel on mixed continuous setting from 2Hz to 100Hz for 15 minutes. Laser therapy was performed on both hips and stifles.  A light effleurage massage was used on the body after each treatment. A custom stifle brace for the left stifle was recommended to help increase stability.

November 6, 2018: “Trixie” was fitted with a custom brace a few days prior and her owners noticed that the brace did encourage her to use the affected leg.  Acupuncture was done with Carbo 0.18 X 13mm at GV 20, GV 14, GV 4 and Bai Hui.  The left hind was needled at ST 36, ST 34, SP 10, SP 9 and BL 40.  The right hip was needled at GB 29, GB 30, BL 54.  Electroacupuncture points were performed bilaterally at BL 19, BL 20, BL 21 and BL 25.   Laser therapy was performed on the right stifle, left hip and lumbar spine.  Her treatment ended with an effleurage massage. 

November 13, 2018: “Trixie’s” gait had improved, and she had partial weight bearing on the left hind leg.  There were mild trigger points noted around BL 19 to BL 25 and around the right hip. She was comfortable during palpation of both stifles and had good range of motion on the left stifle.  There was moderate muscle wasting noted on the left hind leg.  Gluteal muscles around both hips were hypertonic.  Acupuncture was done using Carbo 0.18 X 13mm at GV 20, GV 14 and Bai Hui.  Both hips were needled at BL 54, GB 29 and GB 30.  Both hind legs were needled at ST 36 and ST 34. Electroacupuncture was performed along the spinal BL points bilaterally at BL 19, BL 20, BL 21 and BL 25.  Laser therapy was performed along the thoracic spine and left stifle. The owner was instructed to help strengthen “Trixie’s” hindlegs by teaching her to walk backwards and having her front limbs rest on a slightly elevated surface while she was at her food bowls.

November 27, 2018: “Trixie” was about 80% weight bearing on the left hind leg.  Her posture was normal. Spinal palpation was less reactive, with mild trigger points on the right side around BL 19.  There was mild improvement to the muscle atrophy on the left hind leg.  She was comfortable on palpation of the left stifle.  There was mild buttress on the medial aspect of the stifle.  She received acupuncture with Carbo 0.18 X 13mm at GV 20, GV 14, Bai Hui.  Similar sized needles were used bilaterally at BL 18, BL 19, BL 21, BL 25.  Both her hips received needling at BL 54, GB 29 and GB 30.  Seirin 0.16 X 13mm were used bilaterally at ST 36, ST 34 and BL 40.  Laser therapy was performed on both stifles and hips.  Since the owner reported that “Trixie” was doing much better overall, she was discontinued from robenaxocib. All other treatments were continued.  Owner was also instructed to start some side-to-side weight shifting exercises.

Outcomes, insights, discussions, and references: Prior to my training at CuraCore, I had always recommended cruciate ligament injuries to seek surgical consults, which always ended up in the operating room.  “Trixie” was the first case where I used integrative care through acupuncture, photomedicine, bracing and medicines.  I was impressed that it took about 2 months of treatment for her to be almost 100% weight bearing.  Her progress in the initial 2 weeks (first 2 treatments) were relatively slow and she was apprehensive about her acupuncture treatments.  I was worried that we will not be successful.  After the 3rd treatment, she was less anxious about her visits and she started to use the left hind leg more consistently.  In the following few weeks, the tension of her back muscles lessened as she developed increased stability of the left stifle.  I was pleased by how well acupuncture had help manage “Trixie’s” pain and accelerated her recovery. 

My goal, moving forward is to continue to strengthen the muscles of both hind legs, as well as the muscles surrounding the hips.  I had only used electroacupuncture along the bladder points of her spine.  It will be interesting to see how well “Trixie” will tolerate electroacupuncture on the leg.  I feel that structured physical therapy sessions will contribute to our current treatments. Although “Trixie” still has many months of treatment ahead of her, I feel that her treatment plan to-date has been successful. Having put “Trixie” through surgery for one stifle and medical management for the other, her owners summed it up best when they shared how happy they were to have been given the option of integrative care. 

Two references that relate to cruciate ligament injuries are:

Velázquez-Saornil, J., Ruíz-Ruíz, B., Rodríguez-Sanz, D., Romero-Morales, C., López-López, D., Calvo-Lobo, C. (2017). Efficacy of quadriceps vastus medialis dry needling in a rehabilitation protocol after surgical reconstruction of complete anterior cruciate ligament rupture. Medicine (Baltimore) 96(17):e6726. doi: 10.1097/MD.0000000000006726.

Xu, J., Zhou, X., Guo, X., Wang, G., Fu, S., Zhang, L. (2018).  Effects of Unilateral Electroacupuncture on Bilateral Proprioception in a Unilateral Anterior Cruciate Ligament Injury Model. Med Sci Monit. (24) 5473-5479.