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Acupuncture Diagnosis in Equine Stifle Disease

Acupuncture Diagnosis in Equine Stifle Disease | Equisit Qatar: Horse Physiotherapy & Acupuncture | Scoop.it
Original Research
Acupuncture Diagnosis in Equine Stifle Disease
Pedro V. Michelotto Jr., DVM, PhD, , Luis F.C. Bastos, DVM, Cristina S. Sotomaior, DVM, PhD, Cláudia T. Pimpão, DVM, PhD
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doi:10.1016/j.jevs.2014.05.001
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Abstract
The stifle is a large and complex joint in quadrupeds, including horses, making the diagnosis of stifle diseases a challenge for the clinician. The detection of “stifle syndrome” during acupuncture examination of the equine stifle may be useful for diagnosis of stifle diseases in horses. The aim of the present study was to describe stifle syndrome diagnosis in horses. From 2001 through 2012, 810 athletic horses involved in different disciplines were examined using the technique of acupuncture diagnosis. Stifle syndrome was suspected when the following points were reactive: the sacral point suggestive of stifle disease located at the sacral origin of the biceps femoris muscle, bladder (BL)-20, BL-21, and stomach (ST)-30, together with the three local points in the muscle groove of the posterolateral aspect of the thigh. The diagnostic protocol included radiography and/or ultrasonography in certain cases. The horses were evaluated because of reduced athletic performance, routine or prepurchase examination, hind limb lameness, refusal to jump, inappetence, upward fixation of the patella, thoracolumbar spine or sacroiliac pain, suspensory lesion, and front hoof problems, and 86 (9.4%) were diagnosed with stifle syndrome. The sacral acupuncture point suggestive of stifle syndrome correlated with BL-21, local stifle points, gall bladder (GB)-27, spleen-13, BL-23, BL-52, BL-26, and/or GB-25, ST-30, BL-54 (P < .0001), and BL-20 (P = .003). Twenty-two (25.6%) of the 86 horses with stifle syndrome underwent ultrasonography and/or radiography, and lesions were detected in 21. In conclusion, acupuncture for diagnosis of stifle disease may be considered a diagnostic method to be included in routine clinical examination of horses, and its reproducibility shall be investigated in further studies.

Keywords
Horse; Acupuncture; Femoral; Patella; Chinese medicine
1. Introduction
The stifle is the largest and the most complex joint in horses and comprises three different joint spaces—the femoropatellar, medial, and lateral femorotibial joints. One of the main functions of this complex joint is to maintain limb rigidity when the foot is in contact with the ground, resulting in great stress over each of the joint components [1] and [2]. The term “stifle disease” pertains to lesions related to structures involved with these joint spaces, as well as the patella, patellar ligaments, meniscus, collateral ligaments, joint cartilage or subchondral bone, and cruciate ligaments [3].

Stifle problems have been reported previously in 8% of 835 horses with hind limb and spinal pain [4] and 2% of 5,388 horses with musculoskeletal conditions [5]. Stifle conditions are relatively common in referral practice, and the ability to make specific diagnoses has improved in the last 20 years because of increasing accuracy of diagnostic techniques such as digital radiography, ultrasonography, arthroscopy, magnetic resonance imaging (MRI) [6], and computed tomographic arthrography [7]. De Busscher et al [8] found different types of meniscus lesions in 74 of 130 horses that underwent stifle ultrasonographic evaluation, and McKnight [9] demonstrated the MRI diagnosis of stifle structures in 61 horses evaluated for hind limb lameness. However, even with improvement of diagnostic techniques, clinical examination is mandatory for the diagnosis of stifle disease. Nevertheless, detection of stifle disease on clinical examination remains a challenge for equine practitioners because no abnormalities may manifest on physical examination of the joint, and gait evaluation is not specific for many stifle lesions because the reciprocal apparatus coordinates the movement of the whole limb [3].

In this context, acupuncture diagnosis is a method that has been previously described for diagnosis of lameness [10], [11], [12] and [13] and in prepurchase examination of horses [14] and [15] and has been modestly included in reference texts of equine lameness diagnosis [16].

Moreover, the presence of repetitive patterns of reactive acupuncture points indicating specific conditions of humans [17] and horses [13] has been previously described. Subsequently, the present study aimed to describe the clinical diagnosis of stifle syndrome in a population of athletic horses.

2. Material and Methods
2.1. Animals
Study subjects included 810 horses involved in athletic activities and examined by a veterinarian trained in acupuncture diagnosis (P.V.M.J.) from 2001 through 2012. Horse breeds included Thoroughbreds, Quarter Horses, Arabians, Appaloosas, and Mangalargas, and ages ranged from 2 to 16 years (5 ± 3.6 years). The owners' or trainers' complaints, reactive (painful) acupuncture points detected during palpation, and image diagnosis (radiology and/or ultrasonography) were included in the study. Examination of the patients started with a general physical examination of the exterior aspect (conformation, hoof quality, coat, nutritional status, and apparent lesions), muscle development and symmetry, behavior and mental status (alertness), oral and ocular mucous membranes, and arterial pulse evaluated at the external maxillary artery.

2.2. Acupuncture Diagnosis
The acupuncture diagnosis was performed preferentially at the horse's place of residence and was initiated only after the horse was comfortable with the examiner's presence, being calm and still with relaxed eyes and ears. The examination was initiated with finger pressure over the temporomandibular joints—first gently, followed by the application of firm pressure. Thereafter, the examiner used a rounded plastic needle cover as a probe to thoroughly test the acupuncture energy channels as previously described [10], searching for reactive (painful) acupuncture points, starting on the neck (stomach, large intestine, triple heater, small intestine, gall bladder, and bladder channels) and progressing along the chest (lung-1 and kidney-27), back and abdomen (back Shu points of the bladder channel), and sacral and hind leg regions (bladder, stomach, and gall bladder channels). Finally, front Mu alarm points were investigated. The pressure exerted with the needle cover was always smooth and uninterrupted over the channels so as not to cause fear and anxiety in the horse, initially superficial followed by a deeper pressure. Painful points were identified by a flinch reaction, which usually caused the horse to become uncomfortable and irritated, occasionally moving from the examiner or even trying to bite the assistant or kick.

The same trained examiner evaluated all the horses, using the acupuncture diagnostic pattern as described by Cain [13] and shown in Fig. 1. The condition was suspected as stifle syndrome when the sacral point suggestive of stifle disease, located at the sacral origin of the biceps femoris muscle, was reactive, together with points bladder (BL)-20 (Pi-shu, spleen association point, at the 17th intercostal space, three cun lateral to the dorsal midline in the ileocostal muscle groove) and/or BL-21 (Wei-shu, stomach association point, caudal to the last rib, three cun lateral to the dorsal midline in the ileocostal muscle groove), stomach (ST)-30 (ventral to the tuber coxae at the origin of the tensor fascia lata), and the three local points in the muscle groove of the posterolateral aspect of the thigh.


Fig. 1. 
Equine stifle syndrome acupuncture points as described by Marvin Cain (2003). BL, bladder; ST, stomach.
Figure options
2.3. Additional Diagnostic Procedures
Whenever possible, the examination of horses suspected with stifle syndrome included radiography and/or ultrasonography performed by another veterinarian (L.F.C.B.) not aware of the acupuncture findings and the suspected clinical diagnosis.

2.4. Statistical Analysis
The correlation between the sacral acupuncture point suggestive of stifle disease and the other reactive acupuncture points detected in the evaluated horses was analyzed with the Pearson correlation test by using the software GraphPad Prism 5.0 (San Diego, CA).

3. Results
There were 86 (9.4%) horses clinically suspected of stifle syndrome, two Appaloosas, 21 jumping horses, two Mangalargas, one Arabian, 55 Thoroughbreds, and five Quarter Horses, including 51 (59.3%) males and 35 (40.7%) females. The numbers of cases according to complaint were as follows: 32 (37.2%), reduced athletic performance; 28 (32.6%), routine or prepurchase examination; 10 (11.6%), hind limb lameness; 3 (3.5%), refusing to jump; 2 (2.3%), inappetence; 2 (2.3%), upward fixation of the patella; 2 (2.3%), sacroiliac pain; 3 (3.5%), pain in the thoracolumbar spine; 2 (2.3%), previous stifle joint injections; 1 (1.2%), suspensory lesion in the contralateral limb (on treatment); and 1 (1.2%), front hoof problems.

The consistency of the clinical acupuncture diagnosis was analyzed through the correlation between the sacral stifle suggestive point and other reactive points detected in the examined horses. The sacral acupuncture point suggestive of stifle syndrome positively correlated with BL-21 (P < .0001; r = 0.5608), local stifle points (P < .0001; r = 0.5442), gall bladder (GB)-27 (craniodorsal aspect of the tuber coxae) (P < .0001; r = 0.4815), spleen (SP)-13 (cranioventral aspect of the tuber coxae) (P < .0001; r = 0.4397), ST-30 (P < .0001, r = 0.3644), BL-54 (midpoint of the line connecting Bai Hui, lumbosacral space and the greater trochanter of the femur) (P < .0001; r = 0.3311), and BL-20 (P = .003; r = 0.2387) ( Fig. 2).


Fig. 2. 
Common reactive acupuncture points detected in 86 (9.4%) of 810 evaluated athletic horses diagnosed with stifle syndrome. BL, bladder; ST, stomach; SP, spleen; GB, gall bladder.
Figure options
Points BL-23 (lateral to the second lumbar intervertebral space), BL-52 (lateral to BL-23), BL-26 (lateral to the lumbosacral space), and GB-25 (in a depression halfway between the caudal border of the costochondral junction of the 18th rib and lumbar muscles), related to bladder and kidney in the Five Element theory, also correlated with the sacral stifle point (P < .0001; r = 0.3500).

Positive findings of stifle syndrome were unilateral in 50 (58.1%) and bilateral in 36 (41.9%) horses. Back pain involving the thoracolumbar spine and/or sacroiliac region was observed on clinical examination in 26 (30.2%) horses.

Ancillary diagnosis was performed in 22 horses, and image evidence of stifle disease was found in 21 horses, including degenerative joint disease, arthritis, middle patellar ligament lesion, lesion of the medial collateral ligament of the femorotibial joint, osteochondritis, medial femoral condyle subchondral cystic lesion, and meniscal lesion (Table 1). In one of the horses evaluated by ultrasonography, no lesion was found.

Table 1.
Breed, age, gender, activity, and radiographic and/or ultrasonographic diagnosis of horses suspected of stifle syndrome with acupuncture palpation diagnosis
Breed Age (y) Gender Activity X-Ray or Ultrasonographic Diagnosis
TB 3 M Racing Fracture
TB 2 F Racing Cystic lesion on medial femoral condyle
QH 9 F Three barrels Lesion on medial collateral ligament
Appaloosa 16 M Jumping Meniscal lesion
BH 4 M Jumping Osteochondritis dissecans (OCD)
BH 5 M Jumping OCD and cystic lesion on femoral condyle
BH 7 M Jumping Meniscal lesion
TB 2 M Racing Arthritis
BH 14 F Jumping Degenerative joint disease
TB 4 M Racing Arthritis
BH 15 F Jumping Degenerative joint disease
Mixed 10 F Jumping Arthritis
TB 4 F Racing None
BH 5 M Jumping Lesion on middle patellar ligament
BH 5 M Jumping OCD
TB 3 M Racing Arthritis
BH 9 F Jumping Arthritis
Mixed 9 F Jumping Lesion on middle patellar ligament and meniscal lesion
TB 5 M Racing Arthritis
TB 2 M Racing Arthritis
TB 2 M Racing Cystic lesion on medial femoral condyle
TB, Thoroughbred; BH, Brasileiro de Hipismo; F, female; M, male; QH, Quarter Horse.

Table options
4. Discussion
The present study investigated the usefulness of acupuncture in the diagnosis of stifle disease in athletic horses and its correlation with radiography and ultrasonographic examination findings. Moreover, the role of acupuncture in preventive veterinary medicine was demonstrated in the diagnosis of 2-year-old Thoroughbred horses in race training.

Stifle syndrome has been described as a condition involving the Earth meridians of the Five Element theory, stomach, and spleen [6]. Indeed, it was observed that the sacral stifle point correlated significantly both with BL-21 (stomach association) and BL-20 (spleen association) points, but the strongest correlation was observed with BL-21, suggesting a more prevalent involvement of the stomach than spleen in the evaluated horses.

The diagnostic pattern of stifle syndrome as described by Cain [13] includes the point ST-30 and three local points on the posterolateral aspect of the thigh that significantly correlated with the sacral stifle point in the present study. The point ST-30 described by Cain [13] and Fleming [18], located ventrally to the tuber coxae at the origin of the tensor fascia lata, is described by Xie and Trevisanello [19] as point ST-31.

Moreover, the SP-13 and GB-27 points, related to the tuber coxae and to back and hind limb pain, as well as to athletic performance, were reactive in the evaluated horses and significantly correlated with the stifle point. Although SP-13 is an acupuncture point of an Earth meridian, the significant presence of reactivity in GB-27 in the evaluated horses might suggest the involvement of other hind limb conditions such as concomitant hock or coxofemoral disease as described elsewhere [13]. The hock is connected with the stifle through the reciprocal apparatus; thus, the hock may be compromised in cases of stifle disease or vice versa. Moreover, gall bladder is responsible for tendon and ligaments in Chinese theory [20], which might indicate soft tissue involvement in the evaluated horses. Furthermore, GB-27 is an acupuncture point of the Dai mai, one of the Eight Extraordinary Channels, which affect the circulation of Qi in the hind leg meridians, particularly in the stomach meridian [20]; this might explain its involvement in stifle syndrome of the evaluated horses.

One of the evaluated horses, a 15-year-old jumping mare with a unilateral diagnosis of stifle syndrome, suffered from a recurrent lesion in the contralateral forelimb suspensory ligament. In this case, the radiographic evaluation of the stifle evidenced degenerative joint disease of the medial femorotibial joint. Suspensory ligament lesions usually involve the pericardium meridian [13], which is strongly correlated with the stomach according to the energetic balance method reported by Tan [21]. Metal Element (lung and large intestine), son of Earth in the Creation (Sheng) cycle of the Five Element theory, can also be involved in horses with stifle syndrome because of compensation for the hind limb weakness, resulting in secondary problems of the front limbs. Possible reactivity of BL-13 (lung association point) [13] has been reported, which was not consistently observed in the present case series. However, the diagnostic point large intestine (LI)-16, and not BL-13, was reactive in the present described case (data not shown). Large intestine–16 has been reported in acupuncture diagnosis of front limb lameness [19], as well as suspensory ligament and superficial flexor tendon lesions [22]. Finally, this case shows the importance of investigating other conditions, such as hind limb lesions including stifle disease, in horses with soft tissue injuries such as suspensory desmitis.

Moreover, the involvement of the Water Element in the evaluated horses was observed as reactivity in the related points BL-23 (kidney association point), BL-52, GB-25 (kidney alarm point), and BL-26 (source association point), as well as pain on back and sacroiliac palpation. Furthermore, considering the Five Element theory, the Earth and Water points of the pelvic limb channels are located in the stifle region, and considering the Destruction (Ko) cycle, Earth exerts a controlling force on Water [6] and [11].

The present study shows that, although Thoroughbred horses accounted for most of the stifle syndrome cases, stifle problems occur in horses involved in various athletic activities. Moreover, horses presented for routine or prepurchase evaluation represented the second largest group (after horses with reduced performance) in which stifle syndrome was diagnosed, suggesting that this condition may be present in horses at the start of their career and demonstrating the importance of routine clinical examinations of athletic horses. In the present study, obvious clinical signs such as joint effusion were not described and the classical methods of stifle clinical examination were not systematically performed in every horse. However, most of the cases did not evidence obvious clinical signs, emphasizing the importance of considering stifle disease during the examination of horses with reduced athletic capacity or training difficulties and that acupuncture diagnosis can identify a condition such as stifle disease before clinical signs develop.

Further, one Thoroughbred mare diagnosed with stifle syndrome was the dam of a filly with a subchondral cystic lesion of the medial femoral condyle and a colt that was diagnosed with stifle syndrome, with no ancillary diagnosis and responsive to acupuncture treatment, as soon as it started race training. This finding suggests that the acupuncture pressure examination may be useful in screening for heritable conditions. Moreover, early diagnosis and intervention of stifle disease might reduce training interruptions and positively influence the racehorse career [23] and [24].

Although energetic blockade or imbalance indicated by acupuncture palpation may suggest lesion location, this may not be specific for stifle syndrome, which may be related to the involvement of various joint structures. However, the present study did not investigate the association between the tested diagnostic points and the specific diagnoses. Nevertheless, significant acupuncture findings during clinical investigation of a horse should be further investigated by ancillary diagnostic techniques such as ultrasonography, radiography, arthroscopy, MRI, and computed tomographic arthrography, depending on availability. Ultrasonography and radiography were the techniques used in the investigated horses. These techniques were useful to confirm the diagnosis, enabling lesion identification and the institution of appropriate case management. Acupuncture diagnosis appeared to facilitate reliable diagnosis of stifle disease because the percentage of affected horses (9.4%) in the present study was higher than previously reported [4] and [5].

In conclusion, acupuncture for diagnosis of stifle disease may be considered a reliable diagnostic method and is suggested to be included in routine clinical examination of horses and in reference textbooks for lameness diagnosis.

Limitations of the present study include not testing the method between different operators and not comparing acupuncture with classical techniques for stifle disease diagnosis.

Acknowledgments
The authors thank Pontifical Catholic University of Paraná for the support for publication.

Conflict of interest statement: None of the authors have any conflict of interest to declare.

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Corresponding author at: Pedro V. Michelotto Jr., PhD, School of Agricultural Sciences and Veterinary

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