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  Discussion on Very minor sprain?
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New Member:
mcashman

Posted on Friday, Oct 9, 2009 - 1:09 am:

My 9 year old reining horse staged a remarkable breakout from his pen due to an unknown cause. In the course of his breakout, he knocked down a metal pipe gate, broke down a 4x4 pressure treated post and snapped two older posts as well.

Despite this, on the night of his injury, he was diagnosed only with a lip tear, a small puncture wound on the muzzle, and superficial cuts. He showed no lameness at the walk or swelling.

Two days later, he began to present a lameness in his left rear leg, accompanied by swelling. He also often flipped his lame foot into the fully contracted position when lifting it from the ground when walking. The vet advised that the lameness was a result of inflammation and would take a few days to clear. The diagnosis was that the fluid accumulation from the inflammation was producing the lameness as a result of the pressure of accumulated fluid on muscles and tendons - bute and twice daily cold soaking was prescribed and followed to reduce the inflammation. The inflammation followed its course, the swelling reduced and the lameness declined and disappeared with it.

After another week of no lameness or swelling, with treatment moved from cold soak to warm then cold soak and finally to warm soak alone, I began to consider the prognosis for returning my horse to work. However, I first requested an ultrasound to determine if there was remaining damage that would pose a long term hazard to my horse's ability to perform.

The vet saw a barely observable difference in gait between the two legs, too small to be called lameness. The ultrasound revealed a small amount of fluid in the joint and some submillimeter damage to the tendons at the back of the cannon bone. No control ultrasound of the uninjured foot was performed (I read your article here that recommended that and it makes sense to me). The recommendation was to shoe my horse in a bar shoe, and work him at the walk for the next shoeing cycle with next steps to be determined. The soaking and bute were discontinued.

For the past two weeks I have followed these instructions. The horse continues to show no perceptible lameness at the walk, or on those occasions when he spontaneously trots or canters. He backs up with his normal willingness. Occasionally the join of leg to hoof "pops" - but then, sometimes so does the other foot, and at this point it is not clear that the percentages are really any different. I also have an impression, which photos do not verify, that that outline of the front of the cannon for the injured foot is very faintly more "inflated" than the uninjured foot.

I am wondering what makes sense to expect at the end of the six week cycle and what timeline for return to work might make sense. In reining, these tendons and joints are subjected to sliding stops and torsion from sharp turnarounds and spins.

I'll be having a similar discussion with my vet, but I am also interested in other opinions. From what I have read here and elsewhere, this seems to be a very mild sprain and the information I've found on treatment cycles and protocols seems to be sized for much more serious damage. Thoughts? Suggestions?
Moderator:
DrO

Posted on Saturday, Oct 10, 2009 - 9:56 am:

Welcome Mark,
One of the precepts of giving good online advice is that you never "assume" you know what is going on with a particular horse and case. Decades of experience with clients where I get to discuss the problem on the phone then go and actually see the horse has taught me their assessments of what they are looking at are often wrong or if you prefer a less judgemental tone, their assessment is different than mine.

As a result we cannot really judge how long it will take "your" horse to get well. However we can discuss:
1) compartmental synDrOme (the initial pressure)
2) acute synovitis (the increased joint fluid)
3) popping sound of the joints
4) mild sprain of the (?)
We should also discuss the odd stance you describe in the first paragraph and the vague feeling I get you still think something is wrong with the way your horse moves or stands despite your statements to the contrary.

So where to start. We can dispense with most or your direct questions quickly. If all that is going on are the mild reversible diagnoses' you describe in your post your vet's recommendation seem very reasonable even somewhat conservative, but that is just based on what you write. Following the walking their should be a period of light trot work progressing to canter to see if their has been more serious damage than has been diagnosed. If there is continued joint swelling, intraarticular injections as described in Diseases of Horses » Lameness » Joint, Bone, Ligament Diseases » Arthritis and DJD: An Overview would be reasonable to get that cooled out quickly.

Joint popping is not diagnostic for a problem as many horses do it their whole lives with no history of trouble. However if this is a change possible causes would be joint swelling or joint instability as a possible cause.

Your description of mild swelling on the cannon and the odd flexor flip he initially had makes me wonder in your horses has not ruptured a extensor tendon. Unlike flexor lacerations usually signs are mild but this may require a bit longer to heal, for more on this condition see Diseases of Horses » Lameness » Diseases of the Lower Limb » Tendon Lacerations.
DrO
New Member:
mcashman

Posted on Wednesday, Oct 14, 2009 - 2:02 pm:

Hi, Dr. O

Great comments. You're right, I remain uneasy and yet the items I'm looking at seem subtle and variable and I just don't yet have the experience to be fully confident.

So I had my vet out yesterday to get a sense of progress and she indicated the following:

The odd outline of the pastern and the increased / unusual frequency of (visible not audible, I think) "popping" are probably related. It is her opinion that as we head into the remodeling phase of tendon repair, Lensman is still not entirely willing to put full weight on the limb all the time (though this is improving in frequency) because settling back into the hoof structure in the proper position stretches the flexor tendon and sometimes causes pain. When he finally commits to weighting that leg, he is therefore doing so from a slightly exaggerated forward position for the joint which makes the pop a little more visible as everything snaps back into the right place.

When he is settled back, the pastern takes on a much more normal concavity seen from the side, though I am still not entirely sure / happy that the shape is right, based on cross foot comparisons I am making from digital photographs taken at ground level. I will be trying to ensure he is more squared off when I do the next round of photos to ensure a better comparison.

If there was an extensor tendon injury, it does not seem to be showing up as problems with lifting the toe during the swing phase of the stride, though I may take some video to be sure of this. I am also waiting for an opportunity to watch him urinate, as in the early days of the injury, he was unwilling to stand on the toe of the injured foot in the usual position. This is a position my initution tells me would add strain to the extensor rather than the flexor tendon to keep the toe from collapsing backward and that might be a sign of a hidden injury there. On the other hand, it's a stabilization position, and if the balance between the flexor and extensor is disrupted by flexor pain, that might also lead to tentative use of that position, right?

So what I get from this is:

a) Watch the popping - reduction in frequency indicates reduction in pain as the tendon is stretched. The significant improvement in this already, including willingness to engage the stay apparatus while weighting that foot, suggests that healing is progressing.

2) Watch the outline in normal stance positions. Increased frequence of the right concavity for the pastern will also indicate willingness to stretch the tendon.

3) Other positions such as urination, folding to lay down and unfolding to stand up can also help tell me if he is better.

4) I am not obsessed, but observant, and I need to listen to my intuition about the shape and action of the foot.

In terms of treatment, we have several more weeks of walk to go before increasing the gait. Turns are being kept wide and turns on the injured foot need to be minimized until other signs show normalcy. No pain medication to ensure he gets the right signals to avoid reinjury. Continued work on back up to help with remodeling the tendon to the correct length.

I checked on heat therapy and other related options including ongoing suppression of inflammation or neturophil presence and I didn't see anything that was crisp enough to suggest any of this was unambiguously helpful. The vet when asked also did not recommend anything other than good warm up and cool down. With the cold weather, however, I wonder if some "preheating" might be a good idea before exercise. Your thoughts?

Does all this sound right to you? Any suggestions? Let me know. Thanks!
Moderator:
DrO

Posted on Thursday, Oct 15, 2009 - 10:51 am:

An extensor injury would not cause a problem during the swing phase as the flexors are responsible for folding the pastern and foot back, it would be most evident during the placement of the foot on the ground as the extensor is engaged to bring the foot forward just prior to placement. I think this is further explained in the article on extensor injuries.

Yes flexor pain may be evident by unloading the foot. As to preheating, I am not much enamored with this idea.

Otherwise this all seems fine but is based on your veterinarians appraisal of the injury.
DrO
New Member:
mcashman

Posted on Wednesday, Dec 23, 2009 - 11:31 pm:

Update in December:

Lensman has had a total of three ultrasounds, one for each shoeing cycle. The second showed a tendon change that, comparing the medial to the lateral tendon, indicated 2 mm of enlargement and a slightly ragged area on the medial side. Almost all of the anechoic areas were gone.

We DrOpped the workload from a half hour of under saddle walk to 15 min of hand-walking per day for the next shoeing cycle and left him in bar shoes.

The next visit was for an ultrasound and an x-ray. Lensman was looking much better, and even after having stared at his foot often and long enough to convince him I might be considering eating it, I finally started having to remind myself which foot was injured. Flexibility, elasticity and willingness to sink back on the foot was improving.

A lameness test was performed and cleared, except for an almost invisible stiffness in the hock that improved with movement, according to the vet likely due to lack of work over the last three months.

The ultrasound showed the enlarged medial tendon had shrunken by 0.6 mm back toward normal and the ragged edge was effectively gone. The vet indicated it probably would not shrink much more but she did not expect that to be a problem for tendon strength.

Ultrasound of the pastern joint showed no abnormalities, but an x-ray would be used to confirm.

Ultrasound also showed a thin bright line across the pastern ligament which the vet interpreted as scarring, but the width of the scar was very narrow and the length was also short, and the vet indicated it was not significant in terms of strength.

The x ray showed pristine bones and joints that basically looked as perfect as they had on his pre-purchase, including the area where the two pastern bones connected, which I was the most worried about because of the faint look of knuckling. The ligament attachments looked normal as well.

This exam led to the recommendation to spend one month more hand walking, one month in light under saddle linear walk and then to start normal reconditioning activities.

I hope you find this interesting. Let me know if you think there's anything to think about. Thanks for your earlier feedback.

- Mark
Moderator:
DrO

Posted on Thursday, Dec 24, 2009 - 8:33 am:

Thanks for the update Mark, I would note the same nearly imperceptible lameness was reported in your first note so keep an eye on that but otherwise I see no reason not to go with your vet's assessment.
DrO
New Member:
mcashman

Posted on Sunday, Feb 7, 2010 - 9:11 am:

DrO

I have been walking my horse under saddle for 15 minutes a day for a month since the last exam, not every day, but perhaps four days a week. On video and as observed live by myself or my wife, the horse shows no signs of abnormality at the gait. In fact, the appearance of "knuckling" below the fetlock has essentially disappeared.

However, I am hearing clicking sounds, which seem to be occurring during the swing phase of the leg. The sound may also be coming from the other legs as well.

The ground we are working on is less than ideal, being fairly soft and in some areas four inches or so deep - it is not well cared for, only being dragged once a week or once every two weeks, so it is often irregular in depth and sometimes has pits. I have been looking for alternative board with better footing, but it very hard to find anything better.

It is also very cold here and we are working in high 20's to low 30's.

I have not ridden the horse outside, but this sound does not manifest itself outside when the horse is just walking around, and it seems to happen in the arena when he is just walking around, not under saddle, though perhaps not as much (I will check this more closely today).

The horse was injured in September and has done little work since that time. Based on the last ultrasound / x-ray and vet advice, I am preparing to start him on trot in about a week.

I also recall, at his last board, long before this injury, that I sometimes heard this sound, though I think it was quieter then.

What might be the source of this sound? Is it a sign of the cold and incomplete warm up? Should I walk him by hand for some period before riding? Or is this normal at this stage of recovery? Is it likely to go away in the future? Is the footing creating a risk to his recovery, so that I should more urgently work toward finding him a new home base? Is this otherwise a risk or a symptom of something that warrants more detailed attention, perhaps unrelated to his injury?

Thanks in advance for any perspective you can provide.
Moderator:
DrO

Posted on Monday, Feb 8, 2010 - 7:46 am:

Hello Mark,
Clicks and pops while moving are hypothesized to be either joint fluid transiting small canals rapidly or ligaments snapping into place during movement, are common in horses and not clearly a cause for concern. Since we do not know exactly what it is in your case it is hard to guess what it might mean for the future but by itself I would not spend a great deal of time and effort trying to nail it down.
DrO
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