11/21/2018 - Diagnosing Penn, Part 5 (Treatment)

This took an extra day to get out because of the massive ups and downs my own emotions are taking on an almost daily basis since Thanksgiving. I had settled into a generic dead feeling about all things horses, but all the emotions were stirred up getting the last post together.

Collateral Ligament Badness

So where we left off, the collateral ligaments were #1 on the vet's list, with the coffin effusion and navicular issues neck and neck for #2.

Without treatment on the collateral ligaments, Dr Allen gave him at best, a 30% chance of being sound again. He suggested PRP injections into each CL, with shockwave following each injection. He gave a 40-60% chance of soundness if we did that. He also recommended some shoeing changes to help support the ligaments while they heal.

The shoe on the right is the one they took off Penn. It's his right front shoe, you can see the medial branch is wider and the whole thing is rolled. The shoe on the left is what the vet wants on him instead, but Penn's shoes need the other branch widened. It's basically a regular shoe with a cut of a second shoe welded to the inside. The vet thought steel shoes would eventually get too cumbersome and recommended an aluminum pre-made shoe eventually. And no more pad since that nullifies the effect we're going for.

He said we can also do PRP injections into both coffin joints for the effusion. He said that the injections he got back in August seem to have done their job, but he thought the effusion was coming back and we could readdress it.

The last thing he wanted to address were the navicular issues- he suggested another round of Osphos. He said it lasts between 3 and 6 months, so people generally do Tildren because it lasts about double the time. They end up costing about the same though in the long run.

Doing my due diligence, I asked how much all of these options cost. I already knew the cost of shockwave and Osphos, but not the PRP. Umm... let's call it "cost prohibitive" to do 4 PRP injections, plus 2 shockwave treatments. The cost for 2 PRPs was probably among the more expensive things we've done for Penn, aside from the 5 shockwave treatments that his insurance already covered.

Keeping in mind the reasonable vs unreasonable vs cost, we opted to go short term. Coffin injections and Tildren mean nothing if the collateral ligaments don't heal. We felt, while expensive, the PRP injections for the collateral ligaments were Penn's only real shot at soundness. We also opted for Osphos since while expensive, it's almost reasonable compared to everything else. Lastly, we decided to take new hoof balance x-rays. I didn't realize the ones from August would be considered old by now!

Part of the decision for no PRP injections for the coffin joints is I wasn't sold that Penn's coffins are actually hurting him, which sounds awful. Sure, his coffin joint in both fronts has some funny bone growth, but I'm betting it's always been there and isn't brand new. He was sound at one point in time. He felt a lot better after the steroid coffin injections in August, but about 2 weeks later he started to revert back, so I don't think they did much, and even Dr Cricket said they didn't appear to have worked for him.

We made all these decisions late Tuesday. Penn slept over at VEI so he'd be available when they were ready for him.

_________________________________________

Before I got to the vet office Wednesday morning, they had taken him to the back for his hoof balance x-rays.

11/21/2018
Did you know that horses who 'toe out' generally have P1s that are different lengths on the medial and lateral sides? The medial (inside) side of both of Penn's fronts are drastically different lengths than the lateral (outside). I mean, it wasn't as obvious to me in the previous x-rays, but the first thing I asked was, "I'm guessing it's not normal for the P1 to look like that?" Dr Allen was happy I noticed, and basically said there's nothing we can do about that.

8/16/2018

11/21/2018

8/16/2018

Will his legs ever be perfect? No. Are they better? I'd like to think so. He's still flat footed, but he's less crooked. It looks like he somehow has even less sole in those 3 months... though I will say he had an uneven amount of sole and we did fix that. His toe can still be brought back a bit. After Dr Allen looked at the new x-rays, he did hem and haw over pads- he immediately said, "I can see why Cricket put him in pads." and then had a good think over what he wanted to do, but eventually decided on no pad. The ligament support is more important than the sole coverage right now, and the pad interferes with the ligament support since it goes across the foot.

What I'm curious about, and I didn't talk to Dr Allen about it, but the vet who did Penn's PPE noticed he was crooked and said they could have addressed it as a baby (but then of course she's like, no matter, it's fine!). I'm wondering if he received different nutrition or care (ahem, better... I have many reasons to believe his VET breeder was much closer to a backyard breeder than thoughtful vet breeder), if his legs could have been straighter. Would leg braces have encouraged the bone to grow more on the deficient side?

Dr Allen also said something curious, he thought Penn had a sheared heel on the right front. He pointed out how the inside heel was taller than the outside. Not really knowing what that meant, I said OK and logged it down. He asked for the medial side of the right foot to be trimmed down over time. I had to look it up after I got home, then I immediately went out and looked at Penn's feet.

Top hoof is the right, bottom is the left. Apparently the right foot is sheared. I mean, I see it, but it's very very slight. The right hand side of the picture is the inside of the foot.

I came in while they were finishing up his x rays and putting his neck catheter in to pull blood for his PRP. They shaved his coronary bands at that time too. I did get a chuckle out of that- they always say how good he is and I told them he might be funny about the clippers, and they were like, "Really?" They flicked them on and he immediately became agitated and spooky. I asked that they touch his shoulder with them running and then he'll stand for it. They looked at me like I had 12 heads, but did it, and sure enough he stood like a gentleman and let them shave him... though, he did watch them very suspiciously!

Penn got some time to just be a horse after that. I took him out to hand graze while the team was prepping for his injections and the PRPs were spinning in the centrifuge. 

I got to be there for the PRP injections, and it was absolutely fascinating. I had a real job to do while they were doing that, so I couldn't take pictures of anything, but basically a team of 5 people is what it takes to get this done (vet doing injections with sterile hands, vet working the ultrasound with sterile hands, tech taking x-rays, tech handing everyone else things, and someone to hold the horse).

The method Dr Allen developed to inject PRP into the coffin collateral ligaments is ultrasound guided, x-ray confirmed, and pulling the needle out slowly as he injects. I'll bullet out how everything worked:

• One of the vets did nerve blocks to the entire foot in both front feet to help prevent any pain from bothering Penn while they were injecting.
• Scrub the lateral side of the left front and the medial side of the right front coronary band area thoroughly since the injections will be quite deep.
• Sedate Penn.
• Set Penn's front hooves up on two wooden blocks, since they needed to take x-rays during the procedure.
• They started with the right front. Dr Allen placed the needle while being guided by ultrasound by the other vet, with the extra tech turning knobs and pressing buttons on the ultrasound machine.
• The x-ray tech would place the x-ray plate and aim the hand held unit and take front and side images to make sure the end of the needle was placed in the wing of the coffin bone.
• Dr Allen confirmed placement, then proceeded to 'push the plunger' and slowly draw out the needle, thereby injecting PRP solution up the length of the ligament.
• Repeat for the left front. The right front was placed correctly the first time, but the left front was much more difficult to place. He got it though.
• Pressure is placed over the injection site, especially over the left front because it well hell bent on spewing lots of blood. Ok well maybe it wasn't lots, but blood runs really easily in short alcohol soaked hair, haha!
• Shockwave was done immediately following each injection, and then both of Penn's fronts were wrapped up.

And because I may as well share all the cool shit from this shitshow of a week, I have the placement x-rays too! 

Penn was a champ for his injections, everyone said what a good boy he was. In my head I was like, "How could he not be? You nerve blocked him and sedated him. He should be an angel." Apparently that isn't always enough. He didn't even need to be twitched. That's cool, I'm happy if everyone loves Penn, that means I've done my job in teaching him to behave, even if it majorly sucks. After he woke up a bit (and even at his Friday visit), all of the staff were stuffing him full of treats because they just liked working with him.

Dr Allen was happy with how the injections went. As he was doing the actual injection, I was sitting there thinking, "OMG why isn't it going in? Do they have a bad syringe that's sticking and broken?" He was shaking with effort to get the fluid out of the syringe. Apparently this is a very good sign. It means the tissues are still healthy. He said the horses who he can just squeeze the fluid into easily are generally shredded inside.

So Penn's final notes included:

• Changes to his shoeing with extra wide medial branch of the RF and lateral branch of the LF shoes. Slowly take away from the medial side of the RF to help fix the sheared heel.
• Two more rounds of shockwave to each collateral ligament, for a total of three rounds. He got the first round on 11/21, he got the second on 12/12, and he'll get the third on 1/2.
• Hand walk for a week after he gets home (this is already completed).
• A follow up appointment should be scheduled for 90 days after his 3rd round of shockwave.
• Limited turnout in generally pristine conditions, tranquilize as needed. Keep him as quiet as possible.
• Tack walk 3-5 days a week for 20-30 minutes until his recheck in spring.

They sent me home with a bottle of ace because the "minimal" bouncing he's been doing in turnout is unacceptable- he must only walk and stand. No trotting, bucking, playing, etc. I don't want to use reserpine because of the diarrhea risk, and because those COTH threads were scary. I did talk to a friend who used it on her horse, not knowing about the more rare side effects... and while he was generally fine, he hasn't been the same mentally since).

I've been a bit of an emotional train wreck since this vet visit. First was the, "We have a plan and we'll see how it goes", then the "OMG HE'S NEVER GOING TO BE OK AGAIN", then there was a strange "He's going to be just fine!" period, followed by a more mellow "he's not going to be ok" period. There's a bunch of stuff up in the air, and it won't settle back down until his recheck, which is kind of what I think it killing me a bit. I'm having trouble making it out to the barn to do his walks. I get out there 3-4 days a week now instead of 4-5 that I used to. I'm burned out on horses in general on top of being sad for Penn.

Dr Allen was hopeful I'd be able to start trotting him after his spring recheck, so I think that's keeping me running a bit. Do the rehab properly. Penn deserves it.

11/20/2018 - Diagnosing Penn, Part 4 (Diagnosis)

**First, I want to thank everyone for their kind words and support. It really means a lot. I wish I had better news for how it all turns out, but I don't. Everything is detailed in this post. Part of why this series of posts was so drawn out is because I needed time to go through the almost 700 images from the MRI.**

Despite the bad circumstances, I am completely fascinated with the imaging from the MRI.

MRI day had finally arrived! Everything was going well until Penn absolutely refused to get on the trailer at o'dark hundred. My truck and trailer talk nicely to each other, but the borrowed truck was not speaking to my interior trailer lights. I parked the back of the trailer in a flood light hoping that would provide enough light, but Penn still tripped on the ramp, almost fell down, and then absolutely refused to get in. Mom ended up using her cell phone flashlight to light up the inside of the trailer, and then Penn happily walked on. Unfortunately, that blew the 15 min buffer window I had allowed for slow driving and we ended up leaving at 6 instead of 5:45.

Everything was smooth sailing for our drive to Morven Park, and we even arrived 10 min early! It took me all of those minutes to find someone who could direct us where to go. One of the vets from VEI met us there and helped me get Penn inside and unblanketed. She pulled his shoes (which was an oddly traumatizing event for me, the same sick sad feeling as when we pulled Mikey’s hind shoes when he was recovering in 2015), and then she put his neck catheter in.

I love that VEI’s vets are happy to talk to me and include me in what they’re doing. Doing something as simple as holding the horse so he doesn’t roll in fresh shavings with a neck catheter in was really nice and made me feel useful instead of banished. I was able to tag along for the whole pre-MRI work (but not the MRI itself, which is apparently super boring after the first 5 min, and it takes about 2.5 hours if the horse is good).

A system similar to what scanned Penn.
Check out the website (Hallmarq) that I found this image on for more info!

The standing MRI that Penn had done isn’t like a human MRI. He didn’t need to be knocked out, just heavily sedated so he didn’t move at all. It’s also not nearly as powerful- metal won’t go flying across the room. The only metal you need to remove is anything that will end up in the MRI’s field of view. We had to pull his shoes, and then the vet used x-rays to ensure we got all of the metal from the nails. Slivers won’t get pulled through the hoof, but they will create black spots that the machine can’t see through. It took about a half hour to get the slivers out of his hoof wall- only because the x-ray software wasn’t playing nice and the vet had to keep rebooting the computer between test images. Penn stood like a champ on the Plexiglas foot rest and didn’t move at all. He was just happy to get face rubs and attention.

After getting the metal out of his hooves, we took him back to the room where the equipment is located and they gave him some sedatives and said goodbye to me. They led him to the room with the MRI in it, and I went out to meet my mom and go find some breakfast!

We ended up touring Morven Park's grounds on our way to breakfast. I had only seen the barns and dressage rings, and I couldn't place where they built their new rings. We drove past the mansion, cross country course, soccer fields, before eventually ending up at the part I'm familiar with.

Uh, drool. I hope one day I get to go ride there! There's another area behind that mound that seems to be the same size.

We left Penn around 8:30 or 9 am I think, and the vet called me around 12:45 pm to say he was back in his stall and things had gone well. Penn had been very good for the left foot and left pastern, but had to pee during the right pastern. There was some clean up and they had to redo the right pastern before moving back down to the right foot. Basically, he had been a model patient and could go back to the vet office as soon as he was awake enough to travel.

So drugged, plus a muzzle. Diapers on both fronts since he doesn't have shoes.

It's a good thing we didn't plan on leaving the day of the MRI, Penn wasn't ready to go until almost 1:30 pm, and I was already tired by that point. We took Penn back to the vet office and settled in to wait for practice owner, Dr A Kent Allen, to be done with his clients and to read Penn's MRI.

One of his afternoon clients was GP Trainer with 3 of the horses from her barn, so I got to talk to her for a little bit. She was the voice of reason that I did not want to hear, but I needed to hear. She said that maybe my time with him is up- he is a wonderful creature but served his purpose for me (my bronze) and it's time to find him another job. She told me to do what's best for him, but do not go overboard and do everything both reasonable and unreasonable. Basically, weigh the treatment against how well it works and how much it costs. Come up with a limit of what we'll spend to fix him, and stick to it. She said every now and then she gets emails from clients about older schoolmaster type horses that their owners want to free lease to keep them exercised or to get them off their checkbooks. She could help me get set up with one of those to continue my education. She did apologize for "being an emotionless bitch about it" (her words, haha), but she's absolutely right and that is the voice I need to have on my side. I didn't have it when I bought him. I don't regret buying him, but I believe some of his issues were glossed over or ignored because Mikey had just died and the thinking was "Oh, Jan found a horse she likes, just approve him!"

Anyway...

It took quite a while to get the results back, but that's fine. Dr Allen was very thorough and there's no rushing it. It was well after their closing hours by the time he came to talk about it, but he spent the time with me to make sure I understood what was wrong and pointed everything out on the MRI images, which I've shared below. (I may have gotten the images wrong, or pointed to the wrong place, sorry! I had to find them myself after the fact and it took me a very long time. I am 95% sure of everything though.)

Penn has moderate tears in two collateral ligaments- one in each front hoof, both next to the coffin bone. The medial on the RF and the lateral on the LF, so the left side of each front foot.

PC: http://www.backpunch.com/the-navicular-apparatus/
The arrows are a bit difficult to see, but it's the forward-most green ligament.

To understand all that's wrong with his feet, you need this too. I pulled this image from Google, then added the P1, P2, P3 to it. I didn't know the names of these or the order or anything before any of Penn's issues this year, so I'll list a couple things for anyone who is unsure:
P1: Long pastern bone
P2: Short pastern bone
P3: Coffin bone, pedal bone

In addition to the torn collateral ligaments, his navicular area is a bit messy in both fronts, enough that it bothered the vet quite a bit. He was also concerned about the coffin joint in both fronts. It's just easier to do a screenshot of the MRI findings and diagnosis that Dr Allen gave me:

From my very non-vet perspective, it sounds like Penn should be a cripple for life.
I wonder how many 'sound' horses have some of these issues?

For help reading the following MRI images, look in these places:
     http://www.hallmarq.net/equine/veterinarians
     http://casemed.case.edu/clerkships/neurology/web%20neurorad/mri%20basics.htm
     https://www.chirogeek.com/MRI%20READING/mriReading.html#Axial_Images

I found it helpful to know how each type of sequencing displays the different tissues, and some other basics. Austen found the bottom two articles, the second of which was quick to point out that the label L in the MRI images does not mean lateral, it means left. The images are flipped- what's on the right is actually on the left side of the scanned area. I'm not sure what the F, FP, FA, P, PF and all the other orientation letters mean, but knowing what foot and which side is left makes all the difference. Basically, throw out your medial and lateral references that we've been using! We're looking at the left side of each foot, not lateral (outside) of the foot.

I was able to find most of the issues in the vet notes, so let's go through everything one by one. There were 684 images in 40 different MRI series. Every image is a cross section of the hoof using different highlighting techniques. Series names start with T1, T2, and STIR, which are some scientific way of describing the way the machine scans (for a better description, see those links above!). Each of these highlight the structures in different ways to better see what's going on in there

Some basic structure in the T1W 3D FRO pass from wherever FA is, in Penn's front left hoof. As you progress through the immediate images in this sequence, the P2 comes more into view. Remember, this is a cross section. This happens to be a mostly vertical cross section that is square with the front/back of the hoof.

Of course the first image series called "T2 W FSE SAG" (coffin joint effusion, scar tissue in navicular bursa, navicular bursa effusion) that the vet saw something is the one series I couldn't pinpoint exactly.

The next is the big one. The tears to the collateral ligaments in series "T2 W FSE TRA". There were 3 series done like this, each from different angles: P, PF, and FP. I'm 99% sure that P is "flat", aka completely horizontal. The other two have some upward angle to them, which is why the top pair of images below look funny. The bottom of the image is the frog, cut on a forward angle.

The red arrows point to the torn ligaments. They're cloudy. The right ones are more pronounced and therefore more severe.
The green arrows point to the good ligaments, they show as black empty space.
The last thing these images show is the laminar thickening of the lateral wall in the right hoof (the right side of the right hoof). It took me a long time to identify this one, and I think I've got it right. I was only able to somewhat identify it because I put the right and left images side by side.

To help everyone figure out what they're looking at, here are two image series in GIF format. I put those anatomy pictures up above because you can see the coffin and short pastern bones from a variety of angles, as well as the "pedal" look of the coffin in the P series.

T2W FSE TRA series, PF
As you get closer to the toe, you can see the holes in the coffin bone. I assume those are for blood supply.

T2W FSE TRA series, P
Think of this series as dropping down the leg in horizontal cross sections.
I think this series is fascinating because of image 9, the coffin bone looking like the winged pedal bone, and images 10 and 11, the sole and frog.

Next is the navicular bone edema, in series "STIR FSE SAG". This is a series where water shows up as bright white.

The red circle shows the excess fluid around the navicular bone.

These two series also have a completely fascinating shot of the blood vessels in the bursa on the edges of this cross section of the foot:

The last series that had notable issues was the T1 W 3D ISO series of the left hoof. It showed marginal fractures of the navicular bone on the lateral side (the outside, which is the left side in this case).

It is very hard to see. I had to compare this series in the right foot to make sure I was seeing the correct thing. The arrow points to a thin black line in the lateral part of the navicular bone. That is a fracture.

Because MRIs are fascinating, I took the time to assemble these images and put them into short videos. The following two videos are 112 cross sections of each front hoof, the T1W 3D ISO series, shot from the FA direction.

I do wonder how many "sound" horses are running around with the same hoof issues as Penn (not including the torn collateral ligaments), and whether they actively bother the horse. I know navicular bone damage is kind of common, but what about the laminar thickening? I know we'll never have a good idea, MRIs are not cheap and you don't do them just for funsies.

As fun as it is to look through the images and delve into finding the problem areas, it all comes down to what does it all mean?

Well, it most likely means Penn's competitive career is over, as well as any secondary career he might have had being a schoolmaster. At best, he'll probably be able to W/T/C both directions, with no lateral movements.

The navicular area issues are secondary to the collateral ligament injuries. If left to their own devices, Dr Allen gave the collateral ligaments up to a 30% chance of healing to a point where Penn is sound again. He said this is the kind of injury where you can turn the horse out in a field for 12 months, and the horse will come back in just as lame as it was turned out. Poor blood supply to the hoof means collateral ligament tears as deep as the coffin don't heal well, if they heal at all.

There are things we can do to help, which we did elect to do, that increase his odds of soundness to 40-60%. I'm not sure whether those odds are for return to full work soundness, or return to WTC soundness. I have a feeling they're WTC soundness and the full work soundness is much lower. Lateral movements are most likely out of the question, as well as most hills or other uneven terrain. The collateral ligaments are fairly inflexible and stabilize the lateral flexion of the joints. Penn flails quite a bit as he moves, stressing the inside of the leg the most (note the RF, where the CL is torn on the inside, is the worse of the two tears). He could re-injure them just moving around because of how he moves; there's no need to add lateral movements and more lateral stress to the mix.

So how did this happen? And when? The vets agree that the collateral ligament tears are relatively new (probably in the last few months). The way the nerve blocks went at his visits throughout the summer, he didn't have these issues at the start, middle or end of summer. They most likely happened sometime in September or October. We didn't do nerve blocks at our appointment at the start of October, but his soundness at that appointment was very similar to his soundness at the November recheck.

He could have bounced the wrong way in turnout. He started being more active as he felt better. Our footing changed from dry yet very rainy summer to mucky, muddy fall. Maybe he slipped. I'm an extremely cautious driver when I have the trailer, but it could have happened in there if Penn compensated too hard or the wrong way, or I did something wrong driving and tossed him around. It isn't due to his poor conformation- he tore the left side of both fronts. Something actively happened to him to make that happen. I'm sure his conformation didn't help matters- the whole of his foot is a mess so it was probably already compromised and ripe for injury. I'll never know what happened exactly to end my horse's career, and that's quite sad.

Who knew this tiny amount of lameness, that could be reasoned away as muscle weakness or just simply being unbalanced, is actually two torn collateral ligaments in the front hooves? I certainly won't look at slight off moments the same again.

Link to YouTube

I'll go over the treatments offered and the treatments we did in my next post, as well as his rehab plan. This post has gone on for long enough I think.

11/19/2018 - Diagnosing Penn, Part 3

I am blessed with a wonderful Barn Owner who lets me do things like borrow her truck and drive it to another state and put 600-700 miles on it in one go. TWICE. The first time was after my oil pump failed in 2017. After my truck’s brakes died on our way home from VA, the first call I made was to emergency services, the second was to her to start to arrange transport for Penn to get to his MRI and to get home.

While mom and I were driving back to VA on Monday, Husband called. We had dropped the truck off at our favorite local shop without telling them it was coming, and left it with a big to-do list. The shop had finally called him back. They were concerned because we left them quite a list, and they basically said that with Thanksgiving coming up, them already being 2 weeks deep in existing work, and the amount of parts and labor and comprehensive look over that the truck needed, it could be 3 to 4 weeks before we got it back, and then we're getting into Christmas holiday time. Maybe they were concerned about the amount of time it would take to finish... but really, like we’d say no and have it towed somewhere else? Nah. But that did change things for Penn.

The best shot... has moisture on the lens. Facepalm

We had planned on going to the MRI Tuesday and taking him directly home to PA, with the understanding we’d probably be home before the MRI was fully reviewed and a treatment plan conceived. We were planning on bringing him back a week or so later… whups, not anymore. I’d have to borrow a truck for another 2 days on someone else’s M-F schedule, which I didn’t want to do because I only have 1.5 vacation days left for the year. I made a bunch of calls: VEI agreed to take Penn overnight and squeeze him into someone’s schedule for whatever treatment was decided on (easy to do because he’d be there already), and Barn Owner agreed to let me keep the truck for an additional day.

We got to GP Trainer’s by late afternoon after a nice drive that only had a few driving shenanigans from other drivers. GP Trainer's barn is technically closed on Mondays- no boarders, lessons or riding, just staff taking care of the horses and doing projects that can’t be done with clients around. GP Trainer’s assistant made an exception for me- I needed to drop off grain no matter what, but she said I was allowed to ride if I’d like. So ride I did!

"Hey I'm walking in a field, neato!"

I had planned on schooling in the indoor. When I got there, some of the maintenance staff were working in it and I turned around to go to the outdoor, which also has glorious safe footing and it was a beautiful day out. When I got to the outdoor, I found it had been freshly dragged. Not wanting to disturb it either, I got on and decided a walk through her fields on a pseudo trail ride was just the right thing to do. Penn hasn’t been on a trail ride since May, and she has tons of level field to stroll through.

Just a pretty pic of her indoor and the sunset.

I went for a quick 15 min walk, tucked him back in his stall, packed the trailer with all the non-essentials I needed in the morning, and high tailed it out of there. We were in and out in an hour and 15 min!

I did look over his grain situation while we were there. GP Trainer feeds breakfast, lunch, and dinner, and lunch is fed outside in the turnouts in winter. I found an overturned feed pan of alfalfa pellets out in Penn's dry lot, hahaha! They didn't go over so well then. I figure he ate about half of what they gave him, and I bagged the leftovers and put the rest of the bag in my trailer while he was eating a much more satisfying grain dinner with some of his regular supplements.

Cute face that says, "I do not like alfalfa pellets, Mom!"

The evening was fairly boring, mom and I had dinner and turned in early because a 7:30a MRI appointment meant leaving GP Trainer’s barn by 5:45a, which meant arriving there by 5a, which meant a 4am wake up!

11/16/2018 - Diagnosing Penn, Part 1

Winter decided to rear its ugly head right before we were supposed to travel down to VA for Penn’s recheck. We only got a little ice and snow, but the vet office got a good deal more. They called to say they might have to push appointments back a bit because of a delayed start, which I said was fine because I had already pushed my own appointment back an hour to 2 pm because I was concerned I wouldn’t be able to get out of the barn’s valley.

Not much snow, but it has ice under it.

However, all things lucked out! The snow plow came through as I was hooking up the trailer and salted the steepest part of the road, Penn loaded right up, and off we went! We had a nice drive down to VA, and arrived early despite leaving 45 min later than I originally planned. I ended up hanging around for a bit waiting for the vet to be done with her prior appointment (that's where most of the stall pictures happened- I don't have other media from Friday)

Enter: One feed tub of alfalox.

The vet ran her hands all over Penn first to check pain points and body condition, and found an unreasonable amount of hind end pain. We did the usual tests first- walking on a straight line, trotting on a straight line, trotting both directions on a circle on a hard surface.

He was pretty much the same as last time- 1/5 bilaterally lame on the hard surface on the inside front when trotting. We went over how hit or miss he’s been feeling at trot under saddle. She decided to put the surcingle with 60lbs of deadweight back on since I said it’s worse under saddle and he had quite a bit of hind end pain.

This is where things turned a bit: he became sound with added weight. He wasn’t happy at all, he tossed his head frequently but remained sound. She jokingly called it “the dressage horse response”, aka lift your back and use yourself. She did call it positive for back pain since he was tossing his head.

Penn had enough of gray horse's anger issues and decided to attack, but was not prepared for the gray horse to "fight back".

We went back to the barn and did straight line trots after flexions. The flexions were better than last time: the RF was unremarkable (for the first time ever) and the LF was mild. The hinds saw an increase in pain though- the lower and upper flexions were mild + on the left hind, and moderate on the right.

That left us at an interesting place: his hind end pain concerned the vet especially since I said we’ve battled hind end pain for as long as I’ve owned him, but the front end hadn’t gotten better. She gave me a choice about where best to spend my money: we can redo the nerve blocks on the front end, or we can do a CURO test on the hind end suspensory tendons. She was concerned about the health of the suspensory tendons, citing there is a disease that attacks them and causes irreparable damage, but we often don’t know about it until too late. She said it also could be that he’d benefit greatly from hock injections. Doing the CURO test would make her sleep better about just doing hock injections.

I hemmed and hawed over it, but settled on the front end issues. Those are the one preventing him from being a ‘useful’ horse- he can’t show or go to lessons as he is now. I never know if I’m going to have a sound horse or a lame horse until we’re trotting. As they were scrubbing him up to do nerve blocks in the front heels, I asked how much the CURO test was to do. She said $150. I was like, “Oh, that’s nothing. Let’s do that too if the nerve blocks won’t affect the results.” She was very pleased and we got the CURO test set up after the blocks had been injected.

Penn, I think this is why other horses beat you up so easily. You don't take a hint!

So CURO is kind of interesting- it’s sensors placed on the hind end suspensory below the hock, which are hooked up to a pack on a surcingle. The horse walks back and forth, then trots back and forth, then walks again. Normal output is 5 or above. I could barely find anything out about it online, but here’s a link to their website.

His results were as follows:
LH:
       Overall – 5
       First walk: 4.8
       Final walk: 5.3
RH:
       Overall – 6
       First walk: 6.5
       Final walk: 5.7

Both seemed within normal tolerances, but to me, the left seems worse off… which actually tallies with how he’s felt under saddle. He wants to pitch his hind end left and not use his left hind. The right hind is the more sore hind, so he might be compensating for the left hind. Both results were within normal tolerance, so she thought we would be safe to do the hock injections at some point.

"MAHM HALP"

The first nerve block didn’t produce a change, which was both good and bad. His heels don’t appear to be hurting anymore, which means the shoeing changes we’ve made are working for him. The bad news is that something else hurts.

The next set of nerve blocks blocked the entire foot, and he became much sounder. Well fuck it all. She said that basically puts us firmly in MRI land to further diagnose the problem. We could do that, or continue as we were and see if he gets better or worse. I had prepared to do an MRI on this visit, so we opted for the MRI.

I didn’t realize that VEI doesn’t have an MRI, they use the one at Virginia Tech’s Morven Park medical facility. It has to be booked ahead of time, so we booked it for the first day we could- the next Tuesday morning at 7:30a. Unfortunately that left us in a bit of a lurch for what to do with Penn. I had planned on going over to GP Trainer’s barn that evening and having a simple walk trot rehab lesson with one of her assistants Saturday morning. The vet approved having a lesson- GP Trainer’s footing is practically perfect and extremely safe so she had no issue with walking and doing some limited trot on it.

The problem is the amount of traveling Penn would have to do in the following days: The original plan was to bring him down for his vet visit Friday morning, take him to spend the night at GP Trainer’s, have a lesson Saturday morning, load him up and go home. Well, if we adhered to that schedule, we’d have to pack him back up in the trailer Monday, bring him to either GP Trainer’s or VEI to spend Monday night, then load him up at the buttcrack of dawn to take to Morven on Tuesday, then bring him home again on Tuesday (we would come back for any treatment based on the MRI results since they wouldn’t be available until Tuesday evening anyway). He’d spend 6 hours in a trailer for 4 of 5 days in a row.

Friends?

Luckily, GP Trainer quickly agreed to just house Penn and my trailer until Tuesday. That left me scrambling for feed and blankets for Penn- this was the one visit where I hadn’t brought a bunch of extra feed, nor had I brought any of his turnout blankets! She said they could find something for him to wear if he needed it (he had a BOT mesh sheet and mid weight stable blanket), so that just left the feed problem to be dealt with on Saturday.

To be continued!

Better News?

I was extremely anxious coming up to Penn's next vet check... hence you got the sad and sappy "Still Here" post. I'm trying not to get my hopes up about him healing properly and completely, so I have a ton of back up plans in my head for him. "If he's completely fine or can at least do ABC, he'll stay with me for a while yet. If he can't, but can do DEF, there's plan B. If he's not even able to do XYZ, there's plan C..." Yadda yadda yadda.

This snoot is mine though! Never for sale or given away.

Penn was reset Wednesday last week (2 days before we went to the vet), and I noticed his LF fetlock had a big bump right smack on the outside as I was waiting for the farrier to get his special shoes forged and hammered. WTF horse? Of course I didn't get a picture of it.

Farrier also tried out a new shoe that's a bit bigger and will allow the heels to be set back even further, which the vet wanted when I emailed her pics of his last reset. The shoe also doesn't have a flat surface- the entire bottom that touches the ground is beveled. That is, except where the medial flange of the RF is still pounded wide for support. The new shoes also allowed that to be a bit wider.

Mega pad and shoe.

Friday morning, I pulled Penn out of his stall. The left front had blown up.

Ok, so maybe that's not "blown up", but on a leg that has been tight throughout all of this, it counts as blown up.

I sighed and thought, "At least he's going to the vet today." Wrapped him up in no bows and off we went!

We had a very uneventful drive this time: no K turns with the trailer in driveways due to closed roads, no new chips in the windshield.

Since I was a bit early, I decided to try pulling off his bell boots so the associate vets wouldn't have to... I managed to mangle my thumb in between the boot and his shoe and gave myself a nice blood blister. I decided to just let them pull them off... they're much more experienced with that kind of thing. Turns out they couldn't get them off either. I held his leg, they pulled and the shoes are simply too big for the bell boot to come off over them. Facepalm. I love these bell boots, they're tough and they're big enough to cover that massive set back shoe. I'll have to be smart about pulling them off when he has his shoes reset in show season, but for now, they can stay on.

The first thing Dr Cricket did was check out the LF. The swelling had subsided to practically nothing after being wrapped for 6 hours, and he didn't react to any palpation, so she didn't think there was much to worry about there. She figured he probably banged it on something and to keep an eye on it.

Penn was jogged on the straight line, on a circle on a hard surface, flexed and jogged on the straight line, then went back to jog on a circle on an arena surface.

Verdict?

"Hi, if you're going to just stand there and text on your phone, I need snuggles."

He's still lame.

BUT.

He's sound on the arena surface.

The findings were as follows:

• <1/5 on the LF on hard surfaces tracking left
• 1/5 on the RF on hard surfaces tracking right
• Sound both directions on arena surfaces
• LF lower flexion unremarkable
• RF lower flexion mild/moderate
• LH upper flexion mild
• RH upper flexion mild/moderate

So what does that mean?

• He is doing much better than before- while it is mildly concerning the LF is showing lameness now, the RF has improved considerably so we're on the right track. He has bi-lateral lameness in the fronts (this article is excellent at defining it and symptoms). The RF used to be visible both directions, now it is only visible to the right.
• He is serviceably sound.
• He will probably need hock injections soon.
• He needs more time and very slow reintroduction to work.

The only diagnostic left that Dr Cricket can do is an MRI. She didn't feel it was necessary at this point. She thought more time would give us a better indicator of what's to come for Penn. I'm going to talk to his insurance company to see how much of that they'll cover, so that it is an option when we go back in a few weeks.

So what's causing all this general lameness? Well the answer isn't great. She thinks the tendon has healed sufficiently on the right front, so it's no longer an issue. However, his general foot and leg conformation is working against him. He also wants to stand close up front and walk like a cat with one foot directly in front of the other. Basically, it's how he's put together. That's a super shitty answer, but one I can get behind. Normally a horse like this would have been weeded out in the PPE process and not gone on to the career he's had.

The left front leg is completely rotated out, while the right front turns a bit more from the knee down.
As crooked as his fronts look in this pic... they are straighter than they were. Trust me.

So what's next? Well, it's not all gloom and doom. He's allowed to start trotting again! We're going to start an ultra conservative trotting program:

• Total walk time can increase from 20 min to 25 min. Walk for at least 10 minutes before trotting. All trot needs to be split equally between both directions, and have walk breaks in between trot sets.
• Week 1: 2 minutes of trot.
• Week 2: 5 minutes of trot.
• Week 3: 7 minutes of trot, done in sets of no more than 2-2.5 minutes each.
• Week 4: 10 minutes of trot, done in sets of 2-5 minutes each.

His next appointment will depend on when his insurance runs out- I have 90 days after his policy period end to make further claims. I need to find out the exact details on that, and how much more coverage I can expect, then I'll make a recheck appointment for a week before that date so that I can be sure an MRI won't break the bank if his soundness has gotten worse. He's still going to go back, but I'd like to have at least one more visit be in that 90 day coverage period.

I did ask about equioxx for him- Dr Cricket didn't think we were there yet. She thought there's still some improvement he can make without it. She generally prescribes it for horses that they can't seem to get that last bit of lameness handled. So that's in my head and on the back burner for later maybe.


Despite such a small amount of trot, it's very exciting! I trotted him Sunday, and he felt heavy on the right shoulder both directions (worse to the right) and I had trouble getting his balance shifted in the one minute trot sets. I had to settle for keeping him longitudinally balanced to keep him off his forehand.

I also wanted to note: I did try these CBD pellets for Penn's general well being. They were the only pelleted version I could find, period. I found a single powder too, but it was slightly more expensive and Penn hates powder. I wanted to make sure I could measure it out for the barn staff, and liquid just wouldn't cut it since it would have to be eyeballed or drops counted. The pellets have no detectable THC (obviously I have to take their word for it), which was important because Penn didn't need to be "high" and it had to be safe for me and the barn staff to handle in passing.

I found researching it extremely difficult because there's a lot of anecdotal evidence and not a whole lot of science (free the hemp plant! for science! because you know if it wasn't hemp, it would already have science). Most places said start with a low dose, give it time, and see if you achieved the results you wanted, then increase as needed.

Penn got one scoop in the morning and one scoop in the evening for 1 month (75mg per day) to start.

DOSING GUIDELINES:

General Health: 75mg CBD twice daily has been effective for most average sized horses. Two scoops of pellets contains 75mg CBD. 

Chronic Pain: 100 to 200 mg/day

Anxiety: 50 to 80 mg/day

Pre-CBD Penn: I put up with a lot of his touchiness because he's mine and I love him lots. But by week 10 of our 17 weeks of walking, I wanted to kill him. He would stand in the cross ties and scream for me if I walked around the corner. He was excessively attached, looking for comfort ALL THE TIME when I was near him. He was standing very tall all the time too. He started nipping at horses as they walked past his stall, enough that he needed to have his stall bars closed entirely, no more hanging his head out. He had an excess of energy that was amplifying his needy personality and barn insecurities. I didn't have many riding issues with him, that's when he was on his best behavior. He got a little spooky as time went on, but nothing too far from normal. He was running every chance he got in his tiny turnout.

Post-CBD Penn: He had a day of diarrhea (still solid and turd shaped, but a hair looser than normal). Within a couple days he was back to his old mellow self. He could tolerate being in the cross ties. I could walk away and not worry about him freaking out. He was back to relaxing and taking naps. His eye was just softer. He slowly started to stall walk less, and then eat more since he wasn't spending half his day walking. He didn't scream the minute he heard my footsteps in the barn. He was the same steady guy to ride. He still moved around a bit more than he should have, but it wasn't as bad as before.

After that first month, I upped him to 75mg (two scoops) in the morning and 37.5mg (one scoop) in the evening, hoping to hit that chronic pain threshold. I don't have a verdict on that because a couple days into it, I pulled him off it entirely so it would absolutely be out of his system for his vet check (I allowed 5 days). He went back to stall walking almost immediately during those 5 days.

At a minimum, Penn will stay on it until he goes back to a normal routine. Maybe he'll stay on a low dose to keep his stall walking to a minimum. We'll just have to see!

Well F**k

Alternate Names for This Post:

Feels like Groundhog Day: 7 more weeks of walking!
Reasons to buy a horse with straight legs.
GO TO A CAPABLE VET FOR YOUR PREPURCHASE FOLKS.

He likes it at VEI, he just watches out the window and in general is very relaxed!

I'm going to bet you've gathered Penn's recheck didn't go so well. It's really not all gloom and doom, but this is something I could have avoided by not buying Penn. True story folks.

Oh yea, this also happened on our drive down. A dime sized chip in my truck's windshield.

Let's rewind a bit, last we left off, I had gotten bored out of my mind and trotted Penn briefly because he felt mostly sound at the walk and I wanted to see how the trot went. I knew walking into this appointment that he was still lame. Doing better, but lame. I expected 4-6 weeks of additional walking.

First thing they did was take his temp (they're now monitoring all horses, taking their temp before they set foot in the barn), and do a general body evaluation. She noted that he kept his muscular conditioning beautifully, and I mentioned that I'd been making the most of our tack walking by really encouraging self carriage and lightness of the forehand ("It can only help take weight off the front end right?"). I was worried that actually working him at the walk would be bad, but she approved wholeheartedly about it and didn't tell me to stop what I was doing. She liked how his shoes were- they have great breakover and the toe is short enough. She'd like the shoes set back even more for more heel support though. The RF medial branch is wonderfully wide to support the inside tendon as it heals.

The first test she did was watch him walk and trot on the straight line, where the RF lameness was still there, but only a 1/5! We went down to their covered hard surface round pen, and he trotted again. He was <1/5 unsound on the RF when tracking left, and 1.5-2/5 RF when tracking right.

Back up to the barn we went and did some flexions: The hind flexions didn't bring up anything worth noting, but they did flex positive. Dr Cricket wasn't concerned about them because he didn't trot lame in the other tests; in fact, his hind end was more sound than it was 10 weeks ago (and we had resolved his previous hind end lameness by blocking the front legs). The front flexions were interesting though. Flexing the lower RF made him more lame on the RF (as expected), and flexing the lower LF made him more lame on the RF (what?). She didn't explain why that would be, but happily noted his LF lameness from the previous visit had gotten better.

Look! It's my pretty garden! I'll use it to break up some text.

The next thing she wanted to do was nerve block directly below the strained tendon on the RF. He hadn't gotten that much sounder on the RF in 10 weeks, so she wanted to know if it was hoof or tendon injury that was bothering him.

Nerve block done, off we went for the straight line and circle trots.

Fuckity fuck fuck.

He was 90% sound.

So the problem isn't mostly the tendon, there's a problem in the hoof. Off for x-rays. I asked her to do some shots of the LF too, because we had discussed him possibly having sidebone and I wanted to know. We opted to leave his shoes on since his foot shape is quite wide, and it's a 5 hour drive home. They thought they'd be able to get the angled shots through the shoe (I'm not sharing those because I don't really know what they show), and if they couldn't get what they needed to see, they were going to pull his shoes and I would call GP Trainer and ask for her farrier's number to put them back on.

Well his feet are a bit of a mess internally, and I doubt any of it is new. From what I can glean from his PPE x-rays, now that I know exactly what I'm looking for, I can see traces of all of it. His PPE x-rays are so blurry and low res that it's really difficult to see... so I can see why some of it was missed, but I'm kicking myself now. I would have sent Penn back to his breeder if I got the below news 3 years ago. Sorry buddy. I love him, and I don't really regret buying him, but I would have done the extremely hard thing of sending him back.

Red cicles: remodeling of the coffin bone, worse on the LF, which also has remodeling on the P2.
Red lines: Neutral palmer angle (I may have drawn the line wrong, sorry), aka flat footed.
Yellow arrows: The horns of the coffin bone. They should sit next to each other on this view, not be offset.

SO CROOKED.
Lower red circles: mismatch/crookedness of the joint- the outside of both legs have less space than the inside.
Upper red circle on LF: Sidebone
Vertical lines: The coffin is shorter than it should be from this view (flat footed).
Horizontal lines: The coffin is also crooked. The RF is worse. There is more sole on the outside edge of each hoof in addition to the leg itself being crooked.

Of course by this point, it's all red alarms going off in my head ("My horse is so crooked he's never going to stay sound while in work."). I knew his legs were turned when I bought him, but the twists keep going all the way to the ground internally. The idea I got from his PPE was he would just have some flail in his front legs when moving. Not that I need to be actively getting x-rays taken to ensure we're shoeing him correctly for his internal confirmation. The vets had a very difficult time getting x-rays straight on enough to make an evaluation. Dr Cricket did say something about his navicular bones, but honestly I can't remember what because it was low on her list of issues to deal with, and sounded like it should get better as we correct all the other things.

Any sadness I feel is really being offset by the anger I feel towards his PPE. I can see the sidebone in the PPE x-rays, albeit faintly, but it's there (but it is NBD for now). This level of crooked isn't new. That tilted coffin? Yea, I can see it because in the one side shot, they angled the machine in such a way that the coffin looked straight... and the shoe he was wearing curves right off the bottom edge of the x-ray image and all you can see are the far side nails reaching up to the bottom of the shoe on the near side. I could have sent him back, or I could have prevented a lot of his issues by simply having him shod to the x-rays. He's heavy on the inside of each hoof, meaning without correction, he'll probably keep tearing the medial branch of the suspensory tendon. Don't forget the fetlock joint remodeling that Dr Cricket found in our June visit. That was one the PPE did find and called it nothing. I didn't know any better and I was still deep in Mikey's loss and didn't question it.

Speaking of buying him, we celebrated his 3rd Gotcha Day same day as his recheck. Oh the irony of his PPE being almost 3 years to the day as this recheck.
I got him a belated present, a name plate for his every day halter, just what every horse wants! Lol!

On the bright side, we can shoe to correct a lot of these issues, now that we know they're there. It'll take time, but it's doable. What we can't fix is the coffin remodeling (or fetlock, but that doesn't appear to be an issue as it is significantly less). That will only get worse as he ages and as he works. We decided to inject both of his coffins, even though the RF is the one that's hurting. The LF is actually worse off, so it's actually a good thing that he has more pain in the RF.

Bandaged after coffin injections, and receiving his shockwave treatment.

Another bright side, the ultrasound showed that the attachment of the medial branch of the suspensory is looking great. It is almost identical to the good lateral attachment, but the tendon itself isn't as 'dense' as the good tendon. All that means is he needs more healing time, and more shockwave if we can manage it (we will manage it). He got a shockwave treatment at VEI, and he'll get another 3 weeks later, then he has a recheck at VEI 4 weeks after that.

I finally remembered to ask about a prognosis. She kind of didn't answer the question, but she said we can keep injecting the coffin to keep him comfortable (we'll come back to this), and this is first and foremost a soft tissue injury, which takes a solid 6 months to fully heal. Cue the ridiculously long tack walking... we'll be 17 weeks of tack walking when he goes back for his next recheck. I know she is looking at this in the long view- sound to perform his job like he did before. She's hopeful he'll be healed enough to start trotting after his next recheck. That's about all she was willing to commit to.

I get the feeling that he shouldn't have a problem returning to full work in time- maybe by the first quarter of 2019. I can appreciate that she's looking at this for long term soundness with a low reinjury risk and is taking an ultra conservative approach. Either way, Penn won't be leaving me, ever. I won't sell him or give him away, not knowing what I do now (not that I was planning on it, but things happen). If he can return to 3rd level, but not progress further, I'll work on completing my bronze bar. If he can't do 3rd... we'll see what he can do and I'll work on what part of my bronze bar I can. Then depending on his level of comfort, find a nice AA lady who wants to lease a lower level horse with a ton of experience.

I have a long term tranq on order. He's been generally good, but he's starting to get a little feisty when he's not being ridden. Can't wait for it to get here! I'll stop worrying about him doing stupid things. In the last 2 weeks he's ripped a flysheet, cut his hind leg, and rubbed holes in both hocks. No one ever sees him do more than mosey around and eat hay. If they saw more, they'd catch him and bring him in!

For now, he's having every whim catered to. Including breakfast outside because he simply could not tolerate being in his stall a moment longer, even though he had to be carefully bubble wrapped after his coffin injections.

This is where I'm reaching out the blogosphere think tank:

I am NOT keen to inject his coffins every 6 months to a year for the foreseeable future. He's only 9, if we're only looking at yearly injections, we could do that 10 times before he's 20. I don't think that's a viable plan. He'd need a step down in workload at that point, not injections. Note we're not looking to willy nilly inject him yearly on a set schedule- it'll be when he cues that he's hurting again. 6 months is as frequent as is "safe" but more than a year seems overly hopeful. I've been a bit lax on his Adequan this year (he hasn't had a dose in about a year), but he's going to go back on the single dose every 4 days for 7 doses, every six months. Home vet and I talked about doing Prostride coffin injections instead of a steroid. VEI said we can do steroids until that doesn't manage it, then step up to something I don't remember, then step up again to PRP/APS injections. I've had him on Doc's OCD since he came home from VEI the first time, since it should address bone problems. We will be doing yearly hoof x-rays to keep track of the remodeling.

I'm looking for things (preferably USEF show legal, but usable with withdrawal periods is fine too) that we can do to make his coffin injections last longer. Holistic is fine, a different option than Adequan is worth looking into (I'm not sure how effective it was for him), and cost can be moderate. Barefoot is not an option. He has a vet prescribed plan in place that I intend to keep to. Other than that, I am open to suggestions.

One suggestion I've already looked into is CBD oil (it'll be fed powdered or pelleted), which has gotten a warm response from two of the vets I've talked to that are involved in his care. I'm just having trouble getting a hold of solid information about its use in equine care. I find a lot of "Are you ready to be pain free?" in bold letters on information pages that say a lot without actually saying anything. It needs to be pure and THC free (meaning non-hallucinogenic), and that's about all I've got.

Let the opinions roll!