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  Discussion on Diagnosis and treatment for epitphysitis in 9 month old
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Posted on Wednesday, Jan 9, 2002 - 8:42 am:

I have a colt born March 28, 2001 who had blood drawn for his Jockey club registration on December 7. He was sedated and vet noticed how he was "knuckling under on his forelegs." Very slight heat and swelling around fetlock joints was seen/felt. He had been headbobbing lame 4-5 days earlier for most of one day but that had worn off within 36 hours. I had thought was caused by trauma of running around with 14.1 5yo companion pony or perhaps knocking a leg or being kicked.

When the foal had left the breeding farm where I had him for foaling etc. before our place was ready he was on grain that the farm owner said to gradually increase. So, starting on November 1 when he came home I worked hard on getting more feed into him, classic story -- far too much food. He also had a history of illness and loss so that his growth may have been delayed and once home and being fed what became large amounts of food (8 to 10 pounds 16% protein) he had quite a growth spurt. He also has a build where, although a TB, best way for me to describe it is he has a nice big QH round rump and quite wide chest and barrel, ie, large body conformation, the only weight saving above his legs is the lack of muscle in his neck.

All this as background to fact that he had classic predisposing factors for epiphysitis as my vet terms it, physitis as I think it more accurately was in forelegs. Visual and some palpation were limits of diagnostic techniques. No radiographs taken at all. Treatment was to cut food down radically (he's now on 2 lbs. 16% protein 6% fat pellets, and 1 lb 25% protein Sunshine (Blue Seal equiv to Calf Manna since Jan 4, 3 pounds wet beet pulp, 2 ox trace mineral salt added to grain, and 6 oz of Life Data Labs Growth Formula and strongid C2X since Jan 2, and about 10-14 pound mostly timothy but late cut, lots of heads and stalky, ie, low quality nourishment but not dusty or moldy) and go from 24/7 outside to 24/7 stall rest for a week. Complete stall rest did not work, worked himself into a sweat (in cold weather) in first 24 hours despite the other stall being occupied so that he had company, so we went to 3-4 hours turn out in afternoon and after a week went to turn out for about 10 hours, first in small paddock that is approximately 80' by 140' and then with free access from paddock to 1.5 acre pasture. Both are level but paddock has many frozen divots and unevennesses and ground hard in both though somewhat cushioned by long 8-10" grass in pasture.

I feel his legs twice a day and the small swelling had gone down, all heat gone and he seemed to be moving better than he ever had. So, decided on a relatively warm night Jan 5(lows only in high teens) that would go back to 24/7 turnout with coming in only for grain. Earlier on Jan 5 my sisterinlaw had been visiting and noticed some heat in left hind near fetlock. I kept track of it and when felt it that evening noticed a small scab (which I haven't felt since) and thought, again, oh, he's knocked it playing around. There was no heat either time in right hind.

Feel like an idiot in recounting this history, it is so long and signs/my impatience/prevention in retrospect were so obvious. Anyway, after second night of turn out, when I had been concerned that he wasn't lying down enough to get weight off his legs brought them in a couple of hours early in afternoon and that evening when feeding his near hind was very stocked up. It was a hard swelling all around the leg from his pastern to 2/3 of way up cannon bone, could feel gel-like fluid on inside running from just above widest part of fetlock (don't know bones to refer to -- YET) up about 1" before became part of generalized hard but lesser swelling. It is only slightly warm. The whole lower part of his leg from a few inches below his hock has lost definition because of the swelling, not quite straight but only slight indentations above and below fetlock joint. On his off hind he has slight swelling too but it is about 1/4 to 1/3 the severity of that on near hind. He's been in his stall since then with the broodmare next door. By early afternoon he had developed cowpat diarrhea but by 10 pm last night manure was forming balls that flattened on contact. His forelegs continue cool.


Haven't checked on him yet this morning, this posting is taking far longer than would like, shall post again after see him this morning if his condition has changed.

So, now the questions, vet is coming on Thursday to look at him, in meantime he recommends stall rest, bute, chonDrOitin/glucosamin supplement, he suggested Glycoflex, I suggested cosequin which he described as the state of the art choice and cut protein in grain to 14% (no asking about what type of hay he is getting) and keep within the 3 pounds total a day of concentrate that he is getting. He is also getting a few pounds a day of wet beet pulp, I figured my weight ratio of BP to water is 1:9 so he is actually getting about 3.5 -- 4 oz of dry beet pulp a day. I hate to second guess my veterinarian, a former vet school professor, new to me but seemingly intelligent and young enough I thought, not to be taken in by protein culprit argument. This is after talking last week to an equine nutritionist late last week and she says that his feed level is such that at risk for NOT getting enough protein and should be giving him some of my alfalfa mix hay and that all his minerals, including copper seem balanced and that hay testing is essential as it is by weight main source of protein and of course there is that whole calcium phosporus balance issue.

So, here are my four questions:
1. What to do about diet and how to deal with protein issue? I really don't want to wave a bunch of articles from the internet in vet's face despite him directing me to AAEP website as place to start researching.
2. Use of NSAIDS? Colt doesn't seem in pain, not even that sensitive to touch/pressure on bad leg(s), vet has recommended bute but due to earlier probs colt has had has been diagnosed by another vet as having ulcers (much of his behavior seemed to fit the profile but had seemed to be shaking it off), so I do not want to use bute (another reason do not want to agitate him with too much confinement. As this would be short term use (I assume) am not concerned about relative cost, what would best anti-inflammatory be to use? Are there any external things I should use beyond ice packs or standing in the snow?
3.Should I have radiographs taken of hind and fore fetlock joints? What info for diagnosis, treatment and benchmarking progress/regress would they provide or are signs so gross that xrays are unnecessary? It is precisely because signs are so gross that worry there may be lesions etc that want to know more. But how will more info change treatment? which seems to be, keeping feed levels down, coldpacking, keeping exercise levels down, monitoring state of his legs, maybe administering NSAIDS.
4. How long should I expect him to be on limited exercise and need to be vigilant or expect flareups if he does over-exercise? IE - when can I sit back and relax on this guy who lost his cribbing mother to violent colic June 4 when he was 3 mo, had severe case of strangles most of June and July, had 2" umbilical hernia tied off in late August, was weaned from nurse mare September first, "weaned" from his broodmare band and fellow sucklings/weanlings on October 6 to bond with companion pony, moved here on November 1 and had companion pony promptly fall for broodmare and abandoned weanling, and may be developing cribbing habit?
Thanks for any advice.

Posted on Thursday, Jan 10, 2002 - 9:15 am:

Hello Fiona,
I thought the article should answer all these questions and when I went to it thought it could do a better job. I have rewritten the article and I think it should address all your questions. Let me know if you still have some.
DrO

Posted on Thursday, Jan 10, 2002 - 3:14 pm:

Dear Dr. O,

Thank you so much for the detailed and informative revisions/expansion to the article. Very helpful and reassuring. I read it about 45 minutes before veterinarian arrived and gave me fuel for useful questions.

But does raise a few questions: when you talk about "physiologic response of the physis to weight bearing" as being something less than physitis does that mean physiologic response is not a problem, merely something that occurs in the growing process, and/or is it something more insofar as it could there be considered a to be a spectrum of severity and the response could be a precursor to worse things happening. And if there is this physiologic response is it sending the signal -- watch for contributing factors for physitis and prevent them occurring, eg weight gain, excessive exercise? And conversely, if the thickening/hard edema (not sure if referring to same thing) is present absent other signs, thinking here of lameness, heat, no pain response does that mean healing of physitis?

How long can one expect the leg to remain swollen/thickened? Keep monitoring for this type of condition until two years old?

What is the toxic causation link from alkaloides, are they poisons that attack physis/cartilage/ growth plates?

What do you mean in your article by "There is no indication for greatly adapted diets and may be contraindicated."? Am I correct that, no need to modify diet other than to reduce caloric intake and ensure vitamin, mineral, protein, requirements are being met as would be for normal foal of that actual or expected body weight?

Re exercise and very few repetitive cycles to signal to bones, any info on what very few and very small consist of?? And over what duration of time, ie, may only be 15 minutes but then how much time lapses before need next cycle?? I realize that may lead to very artificial conclusions and in reality application of what you said is more along lines of "don't just put them in a stall and throw away the key, start with reducing how much time can go wild running around and maybe constrain their outdoor environment so can't get up huge heads of galloping steam." At least that is what am applying from my reading, for instance, my colt went out after vet left at about 1:30 today into small paddock and he trotted about total of 40 steps and then has been nibbling hay and doing little bit of walking around (he had been lying down,taking a nap when vet came). This behavior gives me no qualms. As he is quiet (and probably even if he weren't) I plan to leave him out until 6 p.m and then tomorrow, depending on how his legs are in morning let him go out all day with access to his stall in case he wants to come in and nap on shavings on rubber mat instead of mud and snow. And no 24 hour turn out without stall access.

Should vet have palpated the fetlock areas when he was here? I was disappointed because he did only looked at the colt and confirmed our treatment plan we worked out on the phone on Tuesday. Mind you, he felt his fetlocks when first occurred about a month ago, and I am, as you might have gathered from my writing, quite detailed(long winded) in my describing the situation. But wish I had been a bit more pushy as was feeling them again before put colt out and found the little scab/bump on front of fetlock that had lost over past few days. I'm tending to think non-related as was on front not side. (Medial means to me middle, what does it refer to veterinarily?)

We decided not to use any NSAIDs due to colt's seeming lack of pain. Due to his lack of severity of symptoms no radiographs were taken.

I guess I'm one of those "worried well." Thanks very much for bearing with me and helping me become more informed. I hope I'm able to share my expertise and moral support for other HA people the way you have for me.

Posted on Friday, Jan 11, 2002 - 7:46 am:

1) ...does that mean physiologic response is not a problem..
The physiologic response is not a disease process and it is not usually the harbinger of physitis.
2) How long can one expect the leg to remain swollen/thickened?
Sometimes it is temporary but usually horses have to grow into the enlarged bone. Considering there rates of growth at this age that usually is not to long.
3) Toxins and Physitis? They generally work by killing off cells, effecting the physis, metaphysis, and epiphysis. Generally the effects are on thee whole skeletal system with multiple lesions.
4) On your question about the diet: yes.
5) Re exercise and very few repetitive cycles to signal to bones, any info on what very few and very small consist of?? No, though these type measuremenst have been done in humans and to a much less degree adult race horses, none of this will apply well to growing foals. The point here is not to get away with as little exercise as possible but the opposite, try and get as much exercise in as possible that is as close to normal exercise.
6) Should vet have palpated the fetlock areas when he was here?
I really cannot judge your case, perhaps he looked and the presentation was so strongly physiologic he did not fell it necessary?
DrO

Posted on Friday, Jan 11, 2002 - 8:15 am:

I am dealing with the exact same problem in my 15 month old filly, half Arab, half Quarter horse. We obviously fed her too much. I was giving her a scoop which is about 4 lbs. of Purina Mare & Foal a day and she was on good pasture all last spring and summer. Started limping, alternating between her front legs. Vet radiographed her knees, found nothing, said to stall rest her and bute if needed. I would put her up she would get better, let her out and she'd start limping. After 4 months of this we took her to his clinic and he shot at least 25 x-rays. Finally, we found what looks like a little bone spur or calcification on a fetlock bone. Now, if she was a valuable horse that needed to start its training, she would probably go for surgery and have that surgically removed. As it is, the vet thinks we should just cut down on her calories and let her stay out to pasture and see what develops. I see her running at top speed and looking great until she trys to skid to a halt, then she almost always will limp a few steps. I'm just hoping for the best.

Posted on Friday, Jan 11, 2002 - 10:17 am:

Linda,
I think it is improbable your problem is like Fiona's: Her foal had a one time occurence of lameness of unknown cause while you are having recurring episodes of lameness in different legs. Also the age difference of 7 months is an important diagnostic consideration and from the little bit I can glean from your post the physical exam findings are different.

I need to point out that the radiographic change you describe may have no significance, you need some follow up work to determine if this is the cause of the lameness. For more on this see:
1) Equine Diseases: Lameness: The Diagnosis of Lameness in the Horse
2) Equine Diseases: Lameness: The Interpretation of Radiographs.
DrO

Posted on Saturday, Jan 12, 2002 - 9:37 am:

Dr O, once again thanks very much for answering all my questions -- your patience and knowledge and ability to convey it are wonderful. I especially appreciated hearing about max vs min exercise. And an update, after being out Friday from 9 am to 8 pm in small paddock almost no swelling when brought the colt in last night and this morning legs still nice and cold and unswollen except for small swelling at back of fetlock near tendons. I have to attribute that improvement to following your exercise advice. Today he's back out with the other two with free access to pasture and paddock and me home to keep eye on what happens in course of day.

I've been enjoying and learning so much from subscribing to HA but this has been first time had direct need for info that wasn't answered by articles, thanks for being so wonderfully informative and quickly responsive -- when do you ever have time to attend to your live 3D patients and to keep up with all your learning??

Posted on Saturday, Jan 12, 2002 - 10:56 pm:

Thank you sp much, Fiona. Let me be clear about my advise however. No one can accurately diagnose and treat problems without examing a horse. All I can do is provide information on how to go about diagnosis and how to treat specific conditions. You must decide how applicable this is to your situation and diagnosis and treatment must be discussed with your vet. I think you are doing this but I just wanted to be clear. Please let us know how it turns out.
DrO

Posted on Sunday, Jan 13, 2002 - 1:56 pm:

Totally understand re diagnosis limitations, hence some of my qualms re no palpation -- but that is something will be talking over with vet on Monday.

So far so good, slight swelling this morning but this after two extended days out with no mid-day lie down, Today brought in at 1 pm so he can have afternoon nap.

If I learn anything useful rom talking with vet shall pass along, shall next update when swelling gone and stays gone so if anyone interested will see how long process takes to resolve.

thanks again.
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