Let's take a step back. I went for a lesson weekend and Penn was having a bad day during our first and only lesson, and GP Trainer was very concerned about him. I told her we thought it was a hind end weakness issue and she suggested I get a second opinion at Virginia Equine Imaging, her local lameness clinic. They have the ability to x-ray the spine and stifles and all that huge expensive stuff, and are packed full with Olympic and USEF Team vets, so I made the appointment. At worst, I would get a very expensive bill saying his back is weak and he needs to push through it.
Penn's appointment was Monday 6/4 at 1pm, so we drove out Monday morning and arrived just in time. I ended up driving through the Upperville Colt and Horse Show, which looked amazing and I was sad I didn't get to go back to the show to watch (or shop!).
His appointment was with the USEF Dressage Team vet, and as the appointment started, I'm thinking "This has to be the cheapest horse she's worked on in a long time." Cricket was great though, GP Trainer had talked to her about Penn so she had her take on things, she listened to the history of what's been going on and how we treated him so far, felt him all over, praised him for being so well behaved, and treated him like he was a million dollar horse.
She got a baseline of his confirmation and movement first- one of the interns (who is a full fledged vet in her own right, but is basically doing a residency with VEI), jogged him on a smooth surface and lunged him on a hard surface. The vet noted he's close in front- he prefers to walk like a cat with his front legs and put one directly in front of the other. She also noted he's straight in the hock, which wasn't new to me because well, he wasn't a 50k or even 20k horse when I bought him.
They lunged him with 60lbs of dead weight attached to a surcingle to evaluate back pain- horses generally buck or hump their backs if they have any pain at this point. She was pleased that he didn't get worse, and in fact, seemed to get better with the added weight.
Then they flexed him 8 times- lower and upper limbs. I got a bit nervous as she'd flex, an intern would jog him off, they'd discuss a lameness level (mild/moderate), she'd type it into the system, then they'd flex again. Basically every flexion came up lame.
|It's easier to screenshot the notes than to retype it all out!|
Part of the reason I ponied up for a very expensive vet visit is because these people only look for lameness. I could see the unevenness when he lunged on the hard surface on the circle, but couldn't pinpoint what leg. I saw almost nothing on the straight line. I could tell something wasn't right, but I couldn't have told you where. To have him rated between 1-2/5 lame in basically every test was horrifying, because I felt horrible for missing it all, let alone misidentifying it as hind end.
At this point, Cricket knew I wanted to attempt to keep to a budget, so she said she wanted to focus on the front right, even though his right hind felt funny to me. She was more concerned about what's going on in that leg, since he had some bulging over the inner sesamoid bone. She wanted to get him sound up front, and then see what effect that had on his hind end.
Photo Credit: Merck Vet Manual Online
Also, that link has great descriptions of the blocks if you want to learn more!
Off we went to nerve blocks! The first thing she did was nerve block the heel of the right front (distal digital nerve block). This didn't make a huge difference, so she blocked the left front heel (distal digital NB) and what I think is the pastern (proximal digital NB). His left front unsoundness resolved itself, but the right front wasn't completely better.
The next nerve block was a bit more intensive- it required more prep, so he went into one of the treatment rooms to have his leg scrubbed up and receive a low four point NB in the right front. As we left the room to wait for the block to take effect, I mentioned that it looked like Penn was standing squarer, and his right side wasn't so sunken, and asked if it could be because of the nerve blocks? Cricket said that's an excellent observation and yes, as the pain is blocked off, the horse stops compensating and sometimes irregularities work themselves out. Funny how much some horses compensate?
I jogged him off on the straight line and lunged him for the hard circle tests, and Cricket declared him sound. I finally saw the sound horse too. With all the wiggles and compensation out of his motion, I can see what he actually looks like sound and it's lovely. That's a horrible statement, but he's never been easy to find unsoundness because his legs have wobbled and flung so much. His front legs had reach again, the toes pointed nicely, and he happily trotted around.
Cricket again talked to me about the best use of the money available- she wanted to move on to x-ray and ultrasound the right front fetlock to find out exactly what's going on in there before we did anything to the hind end, especially since the hind end looked ok now that the front end wasn't in pain.
We pulled him into a different treatment room, and she said we probably don't have to sedate him for xrays since he's been so good about everything else. (Side note to everyone: the staff enjoyed working on Penn because he stood and took everything they dished out with minimal resistance. He gave them great side eye when they were flexing the front legs and they laughed and noted he's really not sure about what they're doing but was like, "Okaaaaaay..." They complemented his manners and said they don't always have that luxury.) I held him, the intern held the board, vet held the machine (everyone got awesome lead vests), and she snapped 4 shots of the pastern, fetlock area, and lower cannon bone.
Can you spot the issues?
|The side profile of the sesamoid isn't as smooth as it could be (it won't match the arc of the line though).|
The circle show low density spots.
The green semi circle is the good shape of the capsule itself.
|Red arrows point to irregular vascular lines- they should be the same width and they're not. Sesamoid is not as dense as it should be.|
The lower white shadow that's out of place is the ergot.
|Arrows point to irregular vascular lines, the thick horizontal arrow points to rough surface on the sesamoid. Sesamoid is not as dense as it should be.|
Cricket was more concerned about the low density of the sesamoids rather than the arthritis that's starting. I seem to remember some funkiness in that fetlock on Penn's prepurchase, but his x-rays from that visit are so terrible that I can't tell if it's worse or not. (also I found his PPE x-rays after this visit, it didn't occur to me that they might want to see the shitty x-rays)
|I can see some funkiness on the side in the absolutely awful PPE x-rays... but there's no way to compare how bad it was in 2015 vs 2018, the x-ray just isn't clear enough.|
The next thing she did was an ultrasound to check out the state of the suspensory tendon branches, and I'll admit... this is where she completely lost me. I haven't looked at enough ultrasounds to get my head oriented correctly in it, and I don't know the medical terms. I did a lot of research and I'm hoping I got this right. I'm quite sure she knows what she's doing, and if I have pointed something out incorrectly on the x-rays or ultrasound images, that's my own fault because I didn't have enough knowledge when I spoke with her.
|Ligament attachment below the sesamoids. The black in the medial image is the nerve block. It looks like these are in better shape than the suspensory branches, but the medial is still weaker with not as smooth bone attachment.|
|Found on Google.|
So the final verdict:
So what are we doing about it?
Cricket wanted to get the right front under control before we do anything to the hind end.
- Shockwave therapy of the RF medial suspensory branch insertion was performed. 1000 pulses were applied with the R20 trode at E6.
- Two additional shockwave treatments should be done by your home vet: one in three weeks, and one three weeks after that.
- OsPhos administration. 15ml was given IM, divided in four locations (left and right cervical, left and right pectoral).
- Class 4 Laser Treatment, 3x per week, if one can be rented (lower class laser is acceptable, but not ideal). More details to come on that if I can find one to rent. I'd have to ask exactly where it should go, but the goal I believe would be to break up any scarring of the tendon. I might be wrong though. I'm on the clinic's waitlist to rent a laser.
I'll be taking him back to VEI in the middle of August (4 weeks after his 3rd shockwave treatment), which I happened to have already requested time off during the appropriate week for lessons and a horse show... so instead I'll take him to the vet. Cricket will do a recheck, and a new lameness exam. We'll discuss injecting the right front fetlock at that time. She didn't want to inject it this time because the steroid will inhibit the healing of the tendon. Another thing we'll discuss at that time is injecting the hocks or stifles.
So what's happening now?
- Please restrict Penn to QUIET small paddock turnout while he is resting for the RF injury. You may need to use acepromazine or reserpine to keep him under control. Please let us know if you need these medications or advise using them.
|Penn's turnout for the next 10 weeks. We might set up some kind of temp fencing in his regular field when the grass is truly gone from the dry lot. For now, they're haying him out there.|
|Cassi is a huge slut, and Penn is over there sniffing poop.|
- Please limit Penn's exercise to tack walk five times per week for up to 25 minutes. Initially we recommend avoiding excessive graded terrain, deep footing, and lateral work. Lateral work is OK in walk after the second shockwave treatment. (aka, 10 weeks of tack walking- nothing more until his recheck in August)
- Please ask your farrier to adjust his front shoes as follows: set the shoe back to better support the caudal heels and shorten the toe. For the LF foot, we suggest an Onion style shoe, which has a wider branch at each heel region to provide a greater base of support. For the RF foot, we suggest a wider webbed medial branch and narrower lateral branch with a beveled edge at the lateral edge. This is to support the medial suspensory branch while it heals.
|VEI had this handy dandy chart on the wall!|
I guess I've had a NQR horse for so long that I'm not even really upset about missing the season. I'm happy to have an answer, I have a great team who agrees on the plan (oh thank goodness there are no egos), and I've got some other life things I can focus on instead, like losing weight and riding my new bike. I never got around to looking in earnest for a new job. With Penn's NQR, I was afraid to look and spread myself too thin, and even now I'm afraid to leave my job because I need the vacation time to get Penn fixed up.
I don't think we got as far as a prognosis, except I do know he has arthritis in that fetlock so that will eventually end his dressage career. Hopefully we can delay that for a few years, he's only 9. I think I'll get more of a prognosis next time we're there- this was really only half of the work that needs to be done.
|I'll be hurting for content for the next 10 weeks, so you'll be seeing recycled pics, if I have anything new to say anyway!|