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  Discussion on Stifle lameness
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Member:
scrupi1

Posted on Thursday, Jul 24, 2008 - 6:34 am:

Hi Everyone, I have a 6 year old warmblood cross that has had problems with rear leg lameness. I took him to a respected vet in southern pines and he did a lameness exam, the flexion tests were negative, on the lunge he did not track up equally on the left compared to the right and the vet palpated some edema at the left stifle. We did x-rays which were negative for bone cysts/OCD and only showed mild irregularity at the leading border of the left patella which the vet said could be from repeated minor trauma as the knee cap subluxed. He recommended cortisone injections and a month of progressive trot sets to increase strength in the stifles. He said that blocking the stifle is difficult to perform accurately which is why we did not do it and to see if the treatment helped. If so, the horse may benefit from adequan injections and being on a glucosamine product. He said that I should start to see a difference by 2 weeks in his way of going. The reason I took him to the vet was because he started tripping behind, it feels like the left hind collapses underneath him, he is never in danger of falling but it is uncomfortable to ride and I am sure uncomfortable for him. My concern is that it has been two weeks and there is no change in his way of going, he continues to trip at least 5 - 8 times per session, we have worked up to 3, 10 min trot sets with walk breaks between and I know it takes time to build strength but I am getting a little frustrated. The vet bill was about $900 and I can not afford to return repeatedly. I guess my question is, what should my next step be? How long do I continue with the fitness regime before I should see results? I really love this horse and do not want to continue to push him to reach a level that he may not be physically capable of. Does anyone have any experience with similar issues? Thanks!! Susanne
Member:
scooter

Posted on Thursday, Jul 24, 2008 - 8:33 am:

Hi Susanne, My horse did the same thing...feels like they are stepping in a hole almost, he was in VERY GOOD shape at the time. I am fairly certain it is his stifle. I didn't do any diagnostics, basically because I don't have any available. I did talk to the farrier about it and he started moving his break over back and also squared his toes in back. I don't know if the faster break over gave his stifle more relief, but the tripping and "stepping in the hole" went away. At the end of the trimming cycle it would start coming back so I put him on a 5 week cycle at the time and it worked great.
Moderator:
DrO

Posted on Friday, Jul 25, 2008 - 9:17 am:

Susanne, on a carefully done lameness exam is there any sign of lameness other than the tripping? The article Diseases of Horses » Lameness » Localizing Lameness in the Horse describes such an exam.
DrO
Member:
scrupi1

Posted on Friday, Jul 25, 2008 - 12:34 pm:

Dr. O, I have re-read the lameness article and will take a closer look at how he moves this evening. During the lameness exam he moved symmetrically behind trotting straight and was fine lunging at the trot to the left. Trotting to the right on the lunge there is a noticable difference in rhythm, no shortening of the left stride (actually right hind tracks up less) and it is difficult for me to describe, I will try to clarify this evening, but basically it looks like he is not pushing off with equal force. At the canter the vet said that going to the right the left hind leg did not move forward as much as it should although I had a difficult time picking up on that. Under saddle he has absolutely no suspension at the trot (and he used to before this started) and watching him on video undersaddle he is not rounding through the back and altogether looks very stiff. I will analyze again this evening. I hope this helped. Thank you! Susanne (I will also ask the farrier about improving break over - thanks Diane)
Member:
scrupi1

Posted on Thursday, Jul 31, 2008 - 5:58 pm:

Dr. O,
Since Friday I have tried to analyze his gait at the trot and can not see any increase in upward excursion of either hip joint, I do think from reviewing the video that the anterior phase of the left rear is shortened compared to the right. since my last post the tripping has gotten worse, not better and usually happens going down any kind of incline or around corners. I called the vet back and he said to stop riding until we were able to figure out what was going on and he suggested performing a bone scan of the hind end and soft tissues which would cost about $1000 total by their quote. There has never been any blocking of the left hind done, should that be performed before jumping to the bone scan? How can he rule out possible issues in the low back/SI vs. the left hind? I don't mind spending the money if it will give a concrete answer but I have heard horror stories of other diagnostic mysteries that run well into the thousands and would really like to go about things in a logical manner to make sure things are not missed. Thanks for your help, Susanne
Moderator:
DrO

Posted on Friday, Aug 1, 2008 - 7:55 am:

Without signs of lameness that is then localized I cannot understand the significance of a bone scan. Keep it sensible Susanne and ask him what he hopes to learn from such a test. The localizing lameness article has a section on scintigraphy but you already seem aware that a "positive" on this often raises more questions than it answers and is not specific for lameness in general nor sensitive for many particular lameness issues.

The two reasons I see sound horses trip behind are long toes and sensitive soles. The long toes is self explanatory but some horses with sensitive soles when they step on a rock sort of "fall out". Have these been considered and ruled out?
DrO
Member:
dwinans

Posted on Friday, Aug 1, 2008 - 5:56 pm:

Hi Susanne,

My thoroughbred tripped behind pretty bad until my farrier put wedge pads on behind. He looks pretty silly but he hasn't tripped since. I think it was a combination of what Dr O said - long toes and sensitive soles. He also had low heels behind which the wedges fixed.
Member:
scrupi1

Posted on Saturday, Aug 2, 2008 - 10:59 pm:

Thanks Dr. O, I will definitly speak with the vet again and ask for his thought process regarding the bone scan. During the initial lameness exam the vet did use hoof testers and did not pick up on any sensitivity. My farrier was just out about 2 weeks before the tripping started and he is always very aware of correct balance and we have been using him for months. Even when I was leading Harley in from the field today he tripped, again always the left leg and when I say trip it is really more of a collapsing of the hind end that actually is so severe that it elevated the front end because the hind end is going down significantly. One of my past trainers says that he is just long and lanky and has not yet built up the strength. I know that he has grown this year but he is 6 and looks fairly balanced and the tripping happens with every ride. I will speak to my farrier to make sure he is addressing his balance correctly, check back with the vet, and take it from there. Thanks for all of your input. Susanne
Member:
scrupi1

Posted on Tuesday, Sep 30, 2008 - 6:25 am:

I just wanted to give an update on my gelding. I did have the farrier square his hind toes and speed up the break over in front and the tripping was reduced by about 80%. He was back in work for about 3 months doing light trot sets and flatwork in the ring and than came up lame again last week. We went to the vet yesterday and the lameness was obvious this time. He blocked the left stifle and the horse came sound. There was palpable edema (even I could feel it) in the left stifle and we are going to go forward with the bonescan and an ultrasound to further clarify which soft tissue structures are involved (as the x-rays were unremarkable and the lameness can not be attributed to arthritis).
I am going to wait for the results of course before decided whether or not arthroscopic surgery would be an option but the vet said that in many cases depending on the diagnosis, the prognosis for the horse may not be significantly improved by undergoing surgery and may have similar results to prolonged pasture rest (he mentioned 8 to 12 months).
I am going to hope for the best but am not very optimistic as this recurring lameness has been going on for over a year. Just wondering if anyone has had any experience with returning a horse to soundness after an ACL/MCL/meniscal injury. Thanks!
Moderator:
DrO

Posted on Tuesday, Sep 30, 2008 - 7:22 am:

Hello Susanne,
With the lameness localized to the stifle I ask again, "What would be the purpose of the scan?". It is not sensitive enough to separate the various causes of lameness in the stifle and cannot give you a treatment plan or prognose the severity of the lesion. On the other hand many arthritic or OCD conditions that were not visible on radiography initially become more visible with time. Repeating the radiographs, particularly in a university type setting, would be a next logical step in my mind followed by arthroscopic investigation and possible treatment. Of course if this is not part of your goal rethinking the course would be needed but I don't see what useful information the bone scan will give you.
For more on diagnosing conditions of the stifle see the Overview of Stifle Lameness article.
DrO
Member:
scrupi1

Posted on Tuesday, Sep 30, 2008 - 10:42 pm:

Dr. O. I guess I am a little confused. The vet told me that even if I wanted to have an arthroscopic sx performed the surgeon would want to know more of what was going on prior to performing surgery. If the bone scan only shows hot spots, how can it isolate which specific structure is involved? The vet also said that ultrasound was not that successful in visualizing the injured area but recommended it in combination with the bone scan to clarify things. Why would he tell me that the bone scan (which would cost about $1,100) would help guide prognosis when it won't? I have read the stifle lameness article. Is arthroscopic sx than the only way that the injury can be accurately diagnosed?
The problem is the first time he came up lame I gave him 3 months off and than started very slowly back to work. He did well for about 5 months than came up lame again and now again for the 3rd time with not much progression of our work regime. I feel like I need some guidance as to what I should expect. If he needs to be someones occasional trail horse I need to know this as these are not my goals as a rider. Would my money be better spent on foregoing the bone scan/ultrasound and proceeding with the surgery? The last set of x-rays were taken 3 months ago. When would you suggest taking the next set to identify changes?
Thank you as always for your information and input.
Moderator:
DrO

Posted on Wednesday, Oct 1, 2008 - 11:22 am:

The surgeon will want to know as much as possible prior to exploratory surgery but what useful information does your veterinarian think the scan will provide? I agree there is no prognostic information in the scan, does he feel different? Does your veterinarian feel that he can localize specific structures within the stifle using the scan?

Just like radiographs and gamma scans, ultrasound examination of the stifle has limits. However recent studies in the normal ultrasonographic view of the stifle have improved this techinque substantially. In a very experienced user's hands with units specifically designed for viewing these type structures some diseases of the stifle can be visualized. I believe it to be a useful step prior to stifle surgery.
DrO
Member:
scrupi1

Posted on Friday, Oct 3, 2008 - 6:10 am:

Hi Dr. O. I spoke to the vet and he said that because I was not really considering surgery as an option at this point that the combination of the bone scan and the ultrasound would give us the most information regarding proceding with a treatment protocol without undergoing surgery. Which is a bit different from his initial conversation in which he stated the surgeon would need the most information prior to even going forward with surgery. I asked repeatedly if the bone scan would help him to identify the specific structures injured in the stifle and he said yes. I have also placed a call to an orthopedic surgeon at one of the university vet colleges so that I can ask him what he would need diagnostically prior to surgery so that I can be as informed as possible. I will let you know what he says. Thank you!
Moderator:
DrO

Posted on Friday, Oct 3, 2008 - 9:45 am:

Thank you Susanne, keep us up to date.
DrO
Member:
scrupi1

Posted on Wednesday, Oct 8, 2008 - 5:52 pm:

Dr. O. The bone scan and ultrasound were completed yesterday and today. The vet said that the bone scan revealed increased uptake at the head of the femur and the crest of the tibia, a signature indication of an ACL injury, the ultrasound of the stifle showed a healthy medial meniscus, and a healthy MCL but excessive fluid within the joint. The vet has recommended IRAP therapy followed by 3 shockwave treatments to facilitate healing and decrease inflammation and give him the best possible shot at returning to an athletic career. For now we are to put him on limited turn out in a smaller space so that he can not run and injure himself further. The vet said that he has treated 3 cases of stifle injury in the past three months using this protocol and all have returned to their prior careers (one lower level eventing, one competitive driving and the other he could not recall). I am researching IRAP and shockwave and would really like to do what I can for this horse as he has such a great personality, work ethic, and movement.
Moderator:
DrO

Posted on Thursday, Oct 9, 2008 - 8:41 am:

Susanne, is it possible to get copies of the bone scan images and post them here? I would be interested in the diagnosis of ACL injury from a bone scan.

As to the outcome with a acute lameness of 2 weeks duration I would expect a good outcome also but this is just a statistical phenomena. A better prognosis can be determined by knowing the injury present and how severe it is. The key to ligament sprains and strains is rest and anti inflammatories. You will find articles on IRAP and Shockwave therapy at Diseases of Horses » Lameness » Treatment Methods.
DrO
Member:
scrupi1

Posted on Friday, Oct 10, 2008 - 4:19 pm:

Dr. O I am going to try to upload the pictures of the bone scan view.bs
Member:
scrupi1

Posted on Friday, Oct 10, 2008 - 4:36 pm:

The view on the left is acutually the right stifle and the view on the right is the left, injured stifle. I asked about anti-inflammatories and the doctor said no that we didn't want him feeling so good that he would act up and hurt himself. However, the fluid around the joint is still palpable and he is still lame so I did start him on bute and he is still on stall rest.
I guess I don't really understand what significance the bone scan showed me other than the left stifle is definitly the area of injury (which we knew already), it was nice that the ultrasound ruled out MCL and meniscus but we obviously do not know to what extent the ACL was injured, if in fact it was, therefore, I feel that we still do not have a solid prognosis. The treatment he is suggesting is very costly and I expect that if the injury is severe enough that the treatment will not be effective and I will have spent more money on no results. I assume that short of surgery there is no further way to diagnose the extent of the injury. Am I correct?
What would you advise that I do Dr. O. Is there any harm in waiting prior to starting the IRAP treatment? If I had him on stall rest and bute and hosings for a period of time to see if the lameness improved would that decrease the benefits that the IRAP would provide if used immediately? I will really be stretching my budget to the limit but am willing to do so if the suggested treatments really will improve his prognosis. Thank you!
Member:
scrupi1

Posted on Monday, Oct 13, 2008 - 4:51 pm:

I recieved a quote for the IRAP and 3 shockwave sessions, the total was around $2,500 not adding in the additional cost of gas and time off of work to attend all of the appointments. I have been researching on the web as much as possible regarding stifle injuries and have not come across any positive outcomes other than the horse being pasture sound. I am quite discouraged at this point, have a call into the vet to ask him his opinion on an alternative plan so that I will have some direction. I do not feel good about going through with the suggested treatment since we don't know the extent of the injury. Does anyone else have any experience with this kind of situation?
Member:
vickiann

Posted on Monday, Oct 13, 2008 - 7:41 pm:

Have a horse that will fall out in the hind like this when his toes get too long. A farrier that wasn't doing well with him said that it was a stifle problem, but Vets said it was not. I changed farriers. He goes just fine but will begin to have the problem if his toes again get too long. After he is trimmed, he is perfect. Some are more sensitive to extra toe than others are. Hope that you find the answer for your horse.
Moderator:
DrO

Posted on Tuesday, Oct 14, 2008 - 9:59 am:

I have to say Susanne I don't see the diagnosis there either so will have to take your vet's word for this, it certainly remains on the rule out list. However understand that just because areas have increase uptake of radioactivity, this does not always correlate with an area which causes lameness, for more on this see the article on Scintigraphy referenced above.

I believe the next diagnostic step would be surgery. As to waiting versus jumping in with IRAP we really do not have an answer to that question and it certainly depends on the nature of the injury. Since the nature of the injury remains uncertain, even if localized to the cruciate ligaments, your next step depends really on your goals and resources: consider the range from "I want to do everything possible to get my horse well" to "I want to spend as little as possible to see if my horse will get well". Only you can answer the question and from there your next logical step falls out.
DrO
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