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  Discussion on Injury to foreleg proximal suspensory ligament, 6 months on.
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Member:
cathyb1

Posted on Saturday, Dec 6, 2008 - 11:51 pm:

Hi Dr. O,
I have a 3yo warmblood gelding,who was diagnosed in May 08 with an injury to the right fore proximal suspensory ligament. The damage to the ligament, when ultrasounded, showed a hole that was approximately 25-30% of the ligament area. We do not know if the injury was acute at diagnosis - there had been a very slight uneveness present for some months (attributed to footsoreness, and improved with shoeing), and I had seen the horse slip and fall awkwardly some months earlier.
The injury was treated with a bone marrow implant, and then box rest for a month, in a small yard for a month, a bigger yard for another month, and then into the paddock until November. There was no exercise regime during this time, although the vet I was dealing with mentioned it several times, but then decided against it. I had the horse ultrasounded every 6 weeks, and hoped to commence an exercise program each time, only to have the vet say, " Not yet...". I later found out that the Equine Hospital I was dealing with had had success with trotters having bone marrow implants, then just turn out. However,I now know that this is not what most of the current research seems to indicate as the best treatment options.
Ultrasound in October showed a disappointing level of healing of the ligament. The hole had filled in, but there was very little evidence of new fibres or any alignment of the fibres. The prognosis for this horse was not good at this time. I took the horse to another vet hospital, with a good record of fixing leg problems, and they immediately put the horse into an exercise program. They ultrasounded the leg, and these are their comments: " ... fibre and echo score of 2. The thickness of the right fore suspensory ligament was 10% greater than that of the left fore at Zone 1B. Healing appeared to be disappointing, given the time frame after bone marrow injection."
I started the horse on a program of walk and trot (2 weeks of 20 mins walk, then 4 weeks of 40 minutes walk and 5 minutes trot, then increasing to 4 weeks of 35 minutes walk and 10 mins trot). We are 5 weeks into this program. I monitor the horse's leg daily, before and after exercise, and morning and night. I ice the leg for 20 minutes after exercise. There is no swelling, or detectable heat, and when I palpate the suspensory ligament (foot held up and flexed so that I can really get into the ligament), there is no evidence of pain.
However, when he is in his trot work (behind the 4 wheel motorbike, on a firm and level track with one section of gradual incline), I sometimes observe a slight uneveness, suggesting soreness in the right fore. On the lunge on sand, in a small circle, there is slight head nod on the left rein (very slight, hardly noticeable), totally sound in the other direction. Sound on a straight line, except in an active sort of trot behind the motorbike.
He has no shoes on, and tends to wear the toe of the front feet. I am getting him shod in a couple of days, which might improve things.
I am taking the horse back for another ultrasound in 4 weeks, but in the meantime, my vet ( who is some distance away) advises me to keep up with the exercise program until then. But I am concerned that I might be making things worse. This is a very good horse - great temperament, incredible movement, very well bred.
My question is: if there is soreness, enough to produce a mild and intermittent lameness at trot, then wouldn't it show up on palpation? I get no reaction from him on either front leg, and I am prodding and poking pretty hard! I have had sore ligaments myself, and I don't think you can get used to being poked in a sore spot - I react every time!
Moderator:
DrO

Posted on Sunday, Dec 7, 2008 - 4:16 am:

Actually Cathy in most horses without problems you get some resistance to firm palpation of the suspensory so I suspect your horse has become use to being palpated. A chronic lameness that is barely evident at work may not be that uncomfortable with palpation. But it leaves the cause of the unevenness uncertain and if you want further proof this is the cause I would recommend diagnostic anesthesia. I would note that lameness from tendinitis may need to be worked through I have never been able to work through a desmitis: if not rested till well, it recurs.
DrO
Member:
cathyb1

Posted on Monday, Jan 4, 2010 - 4:26 am:

Hi Dr O, Well, it has been a year since I last corresponded with you about this horse. At the ultrasound some weeks after the last post, there was an avulsion fracture of the cannon bone just above the original site of the suspensory desmitis, so the horse went back into a rest/increasing exercise program for 3 months, and was then turned out until 4 weeks ago. During the whole process of increasing exercise, there was a very slight uneveness at trot, barely enough to call lameness... once I started working him again, I could almost imagine a very small head raise when the affected limb was on the outside of the circle. I increased his work under saddle (and I might add that this is a very amenable, trainable horse, with very good natural balance). I took him last week for another ultrasound, which showed the lesion filled in, not with particularly high quality fibres, though. His good suspensory actually has not got a lot of good fibres in it either...
My problem is this; this horse is mainly sound. If he is working very balanced and round, there is not a hint of uneveness (I ride advanced dressage, and can feel it if it is there), but if he is not so balanced, then I can feel the uneveness. Not a huge limp, but definitely there, on an unbalanced corner, for example.
There is no pain on palpation (but never has been), no heat, no swelling. No sign of reinjury on a scan. Is this horse in pain, or is there some sort of scar tissue that is restricting him? I would like to keep training this very talented horse; even if he is not sound enough to do advanced dressage, with his good nature and movement, a good education will stand him in good stead with someone who just wants to do low level stuff or trail riding. Should I give him a rest? Is it usual for horses with this sort of injury to be left with such uneveness? Do I ignore it, and just make sure I develop his very bala nced, steady trot? (He is fine in walk and canter.)
Thanks for your opinion!
Moderator:
DrO

Posted on Monday, Jan 4, 2010 - 7:11 am:

Hello Cathy,
If there is a head bob then the horse is likely in pain. If there is unusual motion of the limb during the forward motion phase or during placement but no headbob, you can conjecture some sort of physical restriction: not a event I have ever seen with suspensory disease.

Which brings us to the second important point: I am not sure this is related to the initial injury. If you decide this is pain related I would recommend you have this evaluated by first localizing it. It may or may not be suspensory related. If it is still the suspensory, I would rest it further but I would have done that last year when I saw the initial rest did not result in lameness. Again, I have not been able to work through suspensory pain.
DrO
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