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  Discussion on Deep digital flexor tendonitis
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Member:
Mbh851

Posted on Sunday, Jan 2, 2005 - 10:19 pm:

I am writing for advice on managing my 15 year gelding diagnosed with DDF tendonitis. I have had him for 4 years and for the last three have dealt with a number of issues, often with the help of this site. We had come through a long period of light work and layups due to hock arthritis, which seemed to have resolved (?fused perhaps)and had been increasing his work over 4 months or so when he begun to develop initially very subtle lameness in the right front.

The farrier first noted it while shoeing and didn't find an abscess so thought he might have a stone bruise. After one month off he was better, but then it recurred after a month back in light work. The vet checked him and he blocked sound with bilateral heel blocks (PDN I believe). Xrays showed no change from prepurchase with "pedal osteitis" and sidebone. She diagnosed a medial collateral ligament strain and recommended "rock and roll" shoes with no restriction as far as turnout/exercise, just the recommendation to rest til he began to improve and advance slowly as tolerated and avoid tight turns and steep grades. The farrier glued the shoes on,and I had a lot of problems with the shoes as he lost them several times over the first month or so, but then did well for about 8-10 weeks. He had half rounds put on during this period. He then begun to be slightly short again just before shoeing, but after shoeing was dead lame for close to 2 weeks.

When he didn't improve I had him rechecked. The vet reexamined him and repeated the blocks and Xrays with the same result except that he had a very thin sole on the right. She recommended glue on shoes with an Equithane (spray on) pad. At shoeing he had severe bruising, and seemed better at first, but again started going short to the right, and was more obviously lame even after being on pasture rest and not worked.

I got a second vet opinion and an MRI was recommended, with the following results and suggestions from the consulting vet at the teaching hospital:

"MR Report

Right Foot

1. Deep digital flexor tendonitis. There are diffuse lesions in the DDFT. Although most of the pathology is lateral, I would be surprised if a lateral block would alleviate the lameness. Moving from proximad to distad:
a. The DDFT proximal to the navicular bursa contains is associated with a noticeable lateral soft tissue mass/signal between it and the suspensory ligament of the navicular bone. The DDFT itself in that region seems intact. See first row of images below.
b. The DDFT beneath the navicular bursa contains diffuse increased signal with central adhesion. See the image in the 2nd row below. Arrow shows adhesion.
c. Distal to the navicular bursa, the lateral aspect of the DDFT is edematous and thickened. That fluid signal extends beyond the insertion on the cannon bone. See the image in the 3rd row.
2. The medial collateral ligament of the coffin joint is asymmetrically enlarged and there is (light colored) fluid signal in its origin in P2. See the last image.
a. I have seen a slight tendency for medial collateral ligaments to be larger than lateral ones in other horses that are not lame, but the signal in the bone of this one is incriminating. The lameness in some of the other CL desmitis cases have improved after a unilateral (medial in this case) palmar digital block. Since the approach problem 1 and 2 would be so different, I would do a medial PD followed by abaxial sesamoid block (if necessary) to see what you get. If soundness doesn’t occur, add the lateral PD. I would use bupivicaine for the abaxial if it is done to avoid the blocks wearing off for the lateral PD block if it is done.

In summary, the overriding finding is the DDFT. That along with the adhesion to the navicular bone is not good. The LF had some similar DDFT findings but not as severe. The point of the added blocks is to tell if the horse has been living with the DDFT problems and the CL sprain is the culprit.

If the DDFT turns out to be the problem, that desmitis has not done well. The best thing I can say about this case is that the focal “core” lesions do not predominate. I would medicate the digital sheath and navicular bursa (if you can). Elevate the heel slightly and confine him to a stall for 3 months. Some have been confined longer, but I would probably walk him some during months 4-6. It is also possible for the DDFT to heal and the navicular bursitis to remain as a problem. The other consideration here is a neurectomy. With the adhesion present, I’ll leave that decision to Dr. XX.

If the CL is the problem, I use a foot cast for 6 weeks, and continued stall rest for another 6 weeks. The end point must be judged then."

The vet here then did the blocks as suggested, and he didn't block sound til the third one, consistent with the DDFT as the active lesion as I understand it.

This foot is slightly clubbed, and also has an old scar through the coronary band on the outside toward the heel with a shelly area in the hoof wall and a tendency to grow faster on the outside. Given the high heel on the right, the second opinion vet didn't think it would be good to elevate the heel further and suggested eggbars on the front and another month of stall rest or confinement to small paddock and re-evaluation at that point. This is a hightly respected lameness expert.

At this point my goals are limited for this fellow, given how many other problems he's had (although those seemed some much better!) and the poor prognoisis I've been given for this diagnosis. He's been primarily a pleasure horse. Although I am reconciled to essentially retiring him, I want to do the best I can to try to get him pasture sound and possibly even to return to some usefulness maybe as a trail horse which sounds like the best I can hope for.

He has now been in the stall 24/7 for 3 weeks, and just got his front eggbars. As the vet indicated that he could go out in a small paddock, as long as the footing was soft, after it thawed here recently I turned him out on in of the small paddocks at the barn where he boards for 2 hours each day for the last 2 days. Although it is small maybe about 25x25 feet, he was able to charge around and buck on first going out.

I have 2 particular questions. Is the turnout too much at this point given that he can move around that much? My second question concerns the recommended regimen for rehabilitating tendon injuries. What I have read seems geared for acute injuries. I work full time and board him, so that hand walking daily 1-2x/day for several months is not realistic, and I am getting some pressure to turn him out at least on a limited basis because of the extra work for the barn staff in a layup situation. However, I feel that he never got adequate rest to allow this to recover given that we were working from another diagnosis.

He's not a performance horse and had limited athletic ability before this, but on the other hand, he is my first horse and I am emotionally committed to doing what I can to get him better. In this situation, with what seems like a more chronic tendonitis, in a horse with more limited goals, would you recommend the same regimen described in the article, one or the other of the approaches from the last 2 vets who have seen him,or an alternate regimen?

Thanks for your input; this has been hard and any suggestions are welcome.

Linn
Moderator:
DrO

Posted on Monday, Jan 3, 2005 - 7:05 am:

Hello Linn,
In 1c above I presume "cannon bone" should read "coffin bone".

If the veterinarian says it is OK for paddock rest then this can take the place of handwalking. You do need to find a way to keep the horse quiter in the paddock: perhaps premedicating with ace before turn out?

The mechanism of injury at this location may not be similar to more typical DDF lesions and don't know how applicable the schedule we give for the more typical types of flexor injury. The navicular bursitis should receive primary intrasynovial treatement with hyaluronic acid and a glucocorticoid steroid. This has been very effective in treating some refractory cases of navicular bursitis.
DrO
Member:
Mbh851

Posted on Monday, Jan 3, 2005 - 2:20 pm:

Dr O,

Thanks for your input; I'll see about giving him ace and talk with the vet about treating the bursitis. Is the mechanism of this type of injury known?

Linn
Moderator:
DrO

Posted on Tuesday, Jan 4, 2005 - 6:11 am:

Unlike behind the cannon, the flexor tendon in this region exerts significant pressure against the navicular bone and must slide against this bone. Besides excessive tension the flexor tendon in this region can be damaged by trauma from this action, particularly if the navicular's flexor surface becomes irregular.
DrO
Member:
Mbh851

Posted on Saturday, Jan 22, 2005 - 8:04 am:

Thanks, DrO. I have one more question. Could incorrect shoeing have contributed in any way to this problem? More than one person raised significant concerns about the way my horse was shod along the course of this problem. Initially I assumed this was a separate issue, but am now wondering if there could be a relationship.
Moderator:
DrO

Posted on Sunday, Jan 23, 2005 - 9:08 am:

Long toes and short heels may exacerbate the condition.
DrO
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