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Discussion on Tears in DDFT
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Member:
lilly
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Posted on Sunday, Apr 12, 2009 - 3:14 pm:
Hi Dr.O,
I have a mare that was diagnosed with tears to her DDFT via MRI. She will be on stall rest for a long time. Luckily she is boarded at a facility owned and managed by a veterinarian and he is working with me to form a "game plan" for treating Isabella. I am not sure about some of the recommendations made by the vet who performed the MRI. I have copied the MRI report and recommendations below. I am looking for advice concerning the injecting of the navicular bursa and the use of the drug Tildren.
Radiographic Findings:
Multiple MR sequences of both front feet are included for evaluation. Right front foot: There is increased fluid within the coffin joint. There is a slight increase signal within the navicular bone on stir sequences. Similar changes noted throughout the toe of P3. There are multiple changes within the deep digital flexor tendon. This includes a high signal tear within the deep digital flexor tendon and medial lobe at the level of insertion on P3. This has a high signal on all sequences. In addition there is a focal area of increased signal on stir avulsion/pulling of the Sharpies fibers at the insertion site. There is a long linear area of intermediate increased signal on all sequences within the medial lobe of the deep digital flexor tendon. This is located within the center portions of the tendon. This begins just proximal to the pastern joint and extends distally to the distal level of the navicular bone. There is mild enlargement of the medial lobe of the deep digital flexor tendon just proximal to the collateral suspensory ligament of the navicular bone. The dorsal border of the deep flexor tendon is irregular at this location. There is an increase in size and signal associated with the collateral suspensory ligament of the navicular bone.
Left front foot: There is a subtle increase signal within the navicular bone on stir sequences. There is a slight increased amount of fluid within the coffin joint and digital tendon sheath. There is mild increase in size the collateral suspensory ligament of the navicular bone.
Conclusion:
The following is a summary of the abnormal findings observed:
Right front foot:
1. There is an acute focal tear in the deep digital flexor tendon at the medial lobe at the level of insertion on P3 with corresponding bone edema. In addition, there is evidence of a long linear area fiber disruption within the medial lobe of the deep digital flexor tendon as described. In my opinion this is likely a more chronic change.
2. Mild changes in the navicular bone suggesting navicular inflammation. This includes a subtle increased signal on stir sequences as well as changes in the collateral suspensory ligament of the navicular bone consistent with chronic desmopathy.
Left foot:
1. Mild changes in the navicular bone suggesting navicular inflammation. This includes signal change on stir sequences as well as changes in the collateral suspensory ligament of the navicular bone consistent with chronic desmopathy.
2. Increase fluid in the coffin joint and digital tendon sheath suggestive of synovitis.
Treatment:
Given the extensive deep flexor pathology throughout the length of the imaging field and the severity of the insertional lesion, consider 10-12 months of controlled athletic rest. Tildren may be administered due to the STIR signal changes noted on both the navicular bone on the left and P3 on the right. Consider corrective shoeing to include extending the heel and an accelerated breakover at the toe. Given the location of the insertional injury, intra lesional intervention may be difficult. Shock wave therapy through a prepared sole on the medial aspect may be beneficial. Consider a non-weight bearing injection of the navicular bursa with hyaluronic acid and a steroid. For the first few months of the convalescence, consider nothing but controlled hand walking. No turn out is recommended.
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Moderator:
DrO
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Posted on Monday, Apr 13, 2009 - 8:36 am:
Hello Ann,
The basis for the navicular injection is sound: evidence of acute inflammation is found and by relieving this inflammation healing can get under way and long term complications prevented. The best to reach the area of the tear and edema is by way of the navicular bursa.
The Tildren (tiluDrOnate) is a bit tougher for me to explain and the question should be posed to the prescriber. I believe the veterinarian is looking at the changes in the navicular bone as signs of disease caused by a inability to remodel quickly enough to changing conditions. An important question is was there any evidence of chronic heel pain prior to the acute tear lameness? We have one published study on the use of Tildren in this case:
Equine Vet J. 2003 Jun;35(4):407-13.Links
TiluDrOnate as a new therapeutic agent in the treatment of navicular disease: a double-blind placebo-controlled clinical trial.
Denoix JM, Thibaud D, Riccio B.
CIRALE/ENVA IPC, Goustranville, 14430 Dozulé, France.
REASONS FOR PERFORMING STUDY: Bisphosphonates, such as tiluDrOnate, are used to normalise bone metabolism via inhibition of bone resorption. Areas of increased bone resorption and formation are typical lesions in a diseased navicular bone. OBJECTIVES: To determine if bone remodelling changes occurring in navicular disease may be corrected with therapies regulating bone metabolism. METHODS: We designed a double-blind, placebo-controlled clinical trial to compare 2 doses of tiluDrOnate, 0.5 mg/kg and 1 mg/kg bwt administered via daily i.v. injections over 10 days for the treatment of navicular disease. Seventy-three horses, split into 2 subpopulations of recent and chronic cases, were enrolled to be followed-up over 6 months. Of these, 33 recent and 17 chronic cases meeting the selection criteria were maintained in the final efficacy analyses. Clinical examinations were videorecorded and reviewed blindly by an independent expert. RESULTS: Horses treated with the higher dose showed optimal improvement of lameness and return to normal level of activity 2-6 months post treatment. The more recent the onset of clinical signs at the time of treatment, the greater the efficacy. The treatment did not modify the response to extension and flexion tests. The lower dose failed to significantly improve the condition. CONCLUSIONS: TiluDrOnate efficacy is demonstrated in the treatment of navicular disease at the dose of 1 mg/kg bwt. POTENTIAL RELEVANCE: Our results support the clinical relevance of bone remodelling changes in the outcome of navicular disease.
I certainly would be interested in the reasoning for the Tildren. We have often discussed Tildren in the past and even have a report of a horse that took part in a Tildren study with favorable results. Run a search on it to read more and you can request how Dawn's horse is doing.
DrO
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Member:
lilly
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Posted on Monday, Apr 13, 2009 - 11:16 am:
Thanks. I believe that the vet recommended the Tildren to address the mild navicular disease. He probably thought it would delay lameness problems associated with navicular. As far as chronic heel pain, Isabella has had so many lameness problems with her right front that I have lost track of every cause! Most of her lameness has been controlled with corrective shoeing. At one point she had on Morrison roller shoes and seemed to do very well in them.
I think I will go with the bursa injections for now and hold off on the Tildren. I am much more concerned with her tendon tears than her navicular problems. Considering Isabella's diagnosis, is there any hope of riding her again?
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Member:
mrose
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Posted on Monday, Apr 13, 2009 - 12:06 pm:
Ann, more problems? Yikes! You have your hands full.
What is a Morrison roller? Is is like a rocker shoe? Or a clog?
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Member:
lilly
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Posted on Monday, Apr 13, 2009 - 12:23 pm:
Sara,
The Morrison roller is a rocker shoe. You can look at it at www.grandcircuitinc.com. Isabella did well in it in the past because of the great ease of breakover. Her hoof literally rolled off the ground.
Not that I haven't had a lot of problems with Isabella, but make sure you're not confusing me with a different 'Ann'. I know there is another subscriber that goes by Ann. I think her username is dres. Not sure though.
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Member:
mrose
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Posted on Monday, Apr 13, 2009 - 12:52 pm:
Ann, you're right, I had you confused with Ann (aka spotsrock) who has had some VERY serious problems with a young mare of hers, a tendon tear.
Thanks for the info on the Morrison. I'm going to look it up. We have used rockers in the past to speed break-over and was wondering if it's the same thing.
Good Luck with Isabella. Is she the horse in your profile? She's lovely, if she is.
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Member:
lilly
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Posted on Monday, Apr 13, 2009 - 1:26 pm:
Ha-Ha. I haven't looked at my profile in so long! That horse is Sebastian, my old gelding that died last year. I guess I need to put up a new picture. Too bad, my son looks so cute in that photo. Now he wants nothing to do with horses!
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Moderator:
DrO
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Posted on Tuesday, Apr 14, 2009 - 6:03 am:
I agree with you Ann on skipping the Tildren from what I know about this. We are still learning a lot about what the significance of MRI lesions and I do not know of any work to support the use of "preventive Tildren" based on MRI found lesions. The metabolic effects of this drug are powerful and in humans not without some side effects.
DrO
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Member:
lilly
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Posted on Tuesday, Apr 14, 2009 - 2:00 pm:
Dr.O,
What about stem cell therapy? Would that help in this situation?
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Moderator:
DrO
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Posted on Tuesday, Apr 14, 2009 - 6:37 pm:
It is a good question and unstudied. You might expect help if the lesion is such that it will "contain" the stem cells. You can't just paste them on top of an open tear, they fall out. But if there is a defect in the tendon that can be injected into, you might find someone to consider it.
DrO
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Member:
lilly
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Posted on Wednesday, Apr 15, 2009 - 9:57 am:
Thanks for the advice. I have one more question. How can I find out if there is any current research underway that Isabella could take part in. It seems like she would be a good candidate for a variety of studies given the fact that she has had an MRI confirming the injury and I have a series of several x-rays spanning over the past 2 years. One study I saw online focused on ddft injuries and the conformation of the horse involved. The researchers involved probably couldn't help Isabella in her recovery but maybe her data could help them. I am not looking for any type of compensation, I am just trying to get something positive out of a negative situation. If someone could learn something from this that would be great.
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Moderator:
DrO
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Posted on Thursday, Apr 16, 2009 - 10:05 am:
Ann I would start with your local veterinary school and engaging someone who specialized in lameness. It may take your veterinarian to initiate contact but my personal experience is that these folks are very open to access, after all it is your tax dollars paying them.
DrO
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Member:
lilly
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Posted on Friday, Jul 3, 2009 - 8:54 pm:
I just wanted to post an update for anyone else in this situation. Isabella is doing great on her stall rest. She gets a one hour walk every day and I think that helps with her mental health. Last week she got an injection in her navicular bursa joint to relieve inflamation. I can't believe how much it affected her behavior. She is acting like her old self again. I never expected to see such dramatic results from the injection. It cost $140 and was worth it.
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Member:
lilly
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Posted on Friday, Jun 25, 2010 - 2:23 pm:
I have a new update to post on Isabella. I am now riding her again. Her work load is very light. I walk her mostly and do a little trot work. Sometimes we ride in an arena, sometimes we ride out on the trail. So far she has remained sound but I am aware of the fact that she could easily injure her DDFT again. The statistics on horses recovering from a severe tear in the DDFT and staying sound are not good. At this point I am not even sure if I will ever ask her to canter again.
The reason I wanted to provide this update is to give hope to other horse owners that have to deal with an injury like this. Isabella was on stall rest for a year and it was a huge commitment for me to hand walk her for an hour everyday. She actually spent only the first 9 months in her stall. She kicked me and I decided to put her in a small paddock by herself for the next 3 months. I was never sure if I would be able to ride her again and I dreaded the thought of getting on her for the first time just to discover she was lame. But I believe the time I spent babying her was worth it. I can only afford to own one horse so that also provided me with motivation to help her heal.
Isabella is not on any type of pain medication and she currently has on normal front shoes (not corrective).
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Member:
mysi
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Posted on Friday, Jun 25, 2010 - 3:09 pm:
Great to hear that your horse is doing well! I'm 7 months into a severe SDFT tear in my pony and it's nice to know a little kid may ride her again one day!
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Moderator:
DrO
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Posted on Sunday, Jun 27, 2010 - 9:20 am:
Thanks for the update Ann and congratulations!
DrO
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Member:
lilly
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Posted on Sunday, Jun 27, 2010 - 5:37 pm:
Melissa,
I rode Isabella this morning and it was our best ride yet. Her trot was smooth and had a good steady tempo. I am now more hopeful than ever that she will be able to handle low level dressage training. I am going to continue riding lightly, only every other day at the most and only 10 minutes of trot work. If she has any relapses or unseen injuries related to her DDFT, I will post them here.
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Member:
lilly
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Posted on Thursday, Sep 9, 2010 - 7:48 pm:
**UPDATE** - On Sunday, September 5, Isabella competed in her first dressage show since 2008. She did awesome! We did Intro A, Intro B, GAG1 and GAG2. She earned 3 second places, 1 third place and reserve champion for Intro level. I have not been cantering her. I figured I would wait until the show season stops for winter and we would gradually add cantering. I ride Isabella 3 days a week and keep careful track of how much trot work she does. I have kept my guard way up looking for any sign of lameness but I think I can relax a little. The bottom line is that there is hope for a useful future for horses that have tendon injuries! They just have to be managed very carefully 
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Member:
lilly
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Posted on Thursday, Sep 9, 2010 - 7:51 pm:
Here is a picture from the show.
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Member:
scooter
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Posted on Thursday, Sep 9, 2010 - 10:02 pm:
Congratulations Ann, beautiful pic. I'm glad your horse was able to overcome this.
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Member:
frances
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Posted on Friday, Sep 10, 2010 - 7:03 am:
That's wonderful Ann! Congratulations to you both!
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Member:
canter
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Posted on Friday, Sep 10, 2010 - 7:14 am:
Great news! and Congratulations!
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Member:
vickiann
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Posted on Friday, Sep 10, 2010 - 1:15 pm:
Good news! Very happy to hear this.
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Member:
lilly
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Posted on Friday, Feb 11, 2011 - 10:09 pm:
**NEW UPDATE** Isabella is cantering without a problem. She continues to stay sound. At the year end award banquet for my local dressage group, Isabella and I were awarded Champion for amateur Intro level
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Member:
mrose
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Posted on Friday, Feb 11, 2011 - 11:05 pm:
Wow! I hope you had a celebration! She's come a long way! Good for you both.
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Moderator:
DrO
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Posted on Saturday, Feb 12, 2011 - 9:16 am:
Congratulations Ann,
DrO
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Member:
vickiann
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Posted on Saturday, Feb 12, 2011 - 11:09 am:
Wonderful news!
Congratulations!
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Member:
lilo
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Posted on Saturday, Feb 12, 2011 - 6:01 pm:
Congratulations, Ann. That is wonderful news! Lilo
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Member:
kpaint
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Posted on Saturday, Feb 12, 2011 - 6:49 pm:
Great news! continued good fortune your way I hope!
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Member:
frances
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Posted on Sunday, Feb 13, 2011 - 6:46 am:
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Member:
canter
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Posted on Sunday, Feb 13, 2011 - 11:46 am:
Fabulous news and a big congratulations!
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