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  Discussion on Check ligament or something else?
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New Member:
cjstumpf

Posted on Wednesday, Mar 10, 2010 - 3:18 am:

Can something other than a forelimb injury cause a nodding lameness? We have a horse with kind of a weird presentation. Here's the history, hopefully Dr. O or someone has seen something similar:

Our 11 year old appy-X gelding played in the mud. The next day, when I brought him out to ride, he was sound at walk but had a very slight nod RF at trot on dirt footing. No heat or swelling or pulses, but he palpated positive high on RF just under and behind the knee.

I buted 2 gm that night and 1 gm next morning, applied standing bandages over sore-no-more, and did not work him.

He looked better the next evening but since he was on bute I still did not work him. 36 hours later he still didn't look quite right so I took him to the clinic when they next had space, which was day 5. He's stoic, I wouldn't do this with a wimp.

Exam:
1) Lame 2/5 RF
2) RF palpates positive immediately under R knee in suspensory/check ligament area however no obvious heat/swelling.
3) RF hoof tester negative
4) RF suspensory block negative
5) uSound show no obvious pathology of any structure, and comparison uSound shows the pattern is identical between L and R check ligaments. However RF check ligament area vascularization differs from LF check ligament area vascularization, and RF check ligament appears larger than LF.
5A) NB: thickened RF check ligament and large external blood vessel also noted in an 8/2005 exam but the check ligament was fine then (BUT he DID sprain it in 3/2005 crawling under his stall guard while laid up for something else!).
6) RH flexion positive (Not sure if vet performed hock or hock/stifle flexion)
7) RH hip moves high and RH anterior gait phase abnormal - limb swings out
8) LH flexion possibly positive (moved best of all after LH flexion, however this was also ~35 minutes post suspensory block so it's possible the block had now "leaked" to more forelimb structures)
9) Low back soreness but unclear whether primary of secondary.

Preliminary diagnosis and recommendation: RF check ligament injury. 7-10 days stall rest or SMALL paddock turnout in paddock near to barn. no bute, Back on Track wraps and sore-no-more (arnica) ok. recheck in 7-10 days.

Back at home taking a lead from the vet exam, I took another look at his back and hindquarters. This horse is VERY sore on the right side of his back over a 6" area behind the last rib and in front of the SI area, and I get the feeling that the soreness extends down and possibly involves the right stifle. His back is more reactive than his RF ICL area.

After reading Dr. O's article on the ICL, I get the impression that an acute ICL injury would normally present with more lameness and more swelling, and the old ICL findings from 2005 and the lack of pathology on the ultrasound last week seem to suggest that the ICL hasn't changed in 4 years.

However he does palpate up high (though not the first time you squeeze) and he did have that RF nod. Is there any chance that is a red herring? Could an injury to the right side of the back or high on the right hind cause an upward nod as the RF came down at the jog???

Other history: This horse does have a history of SI pain and has been injected for it tho with no obvious results. Also he suffered fructans-induced laminitis in 2007 with RF damage and though cleared to jump again and consistently sound and negative to hoof testers, that hoof capsule is more upright now.

He jumped around the Florida Horse Park XC course within the last year and was examined after from stem to stern by Blue Water Equine (then associated with Rood & Riddle) and pronounced fine. He has also competed in low level dressage scoring up to 73% in the last year. Not sure it's relevant but he WAS sound after the hoof and back ailments :-)

Ideas? Thoughts? Commiseration? ;-)
New Member:
cjstumpf

Posted on Wednesday, Mar 10, 2010 - 12:46 pm:

I just read the Localizing Lameness Article (sorry I hadn't found it before posting, I did read the ICL an the upper hind limb articles and all the ICL posts) and found this quote:

"A horse appearing lame on both a front and rear leg on the same side should start with an examination of the rear. With lameness on the diagonals you start with the front leg. If when you block out (see below) the lameness the other lameness disappears also you know you are dealing with just one lame leg."

Based on reviewing the initial post about the symptoms and exam results, and the Localizing Lameness article (particularly the section on looking at symptoms in both front and rear on the same side) I am concluding that we should be looking more carefully at the hind limb and back as trouble sources, does that interpretation seem correct? Thanks in advance.
Moderator:
DrO

Posted on Thursday, Mar 11, 2010 - 7:50 am:

Welcome back CJ,
I don't follow the diagnosis or agree with some of your alternate thoughts:
1) What do you mean by a suspensory block? If this is a high volar block this should block out block out a ICL desmitis.

2) ICL desmitis often starts as a mild ill defined lameness.

3) From your post it is not clear that there is any evident hind limb lameness making how your second posting applies.

It strikes me if the current diagnosis is questionable you should have the ICL blocked and if it does not block out there start looking elsewhere. All else is conjectural at this point.
DrO
New Member:
cjstumpf

Posted on Thursday, Mar 11, 2010 - 5:49 pm:

Hi Dr. O, thanks!

1) Yes it appears to have been a high volar block, the place the needle went in matches the diagram/description I just looked up. The vet called it a suspensory block. I had understood him to feel it was affecting the suspensory and not the ICL but it appears I misunderstood. Regardless, the gait was unchanged after the block, the horse had the same slight nod.

From what you wrote then, we probably do not have an ICL-induced lameness because a high volar block would have caused the horse to go sound?

2) Understand.

3) The horse hikes the right hip and swings the right leg outwards as the limb travels forward, when compared to the left hip and the left hind path of travel. Also the right hind flexion was more positive than the left hind flexion. (However I am not sure which flexion position the vet used). Also the back palpated sore on the right (off) side in a section from behind the last rib to before a line from point of croup to point of hip.

Also, bute helped.

I hope it's ok to ask this question: Based on this information, where would you look next?

Thanks!
Moderator:
DrO

Posted on Friday, Mar 12, 2010 - 7:35 am:

For me to say you probably do not have a ICL desmitis means I believe that a high volar block was done in a manner that would block the ICL, your vet says it wasn't.

If the horse is telling you by the change in gait that the lameness is in the right fore yet you do not believe the veterinarian I would have the ICL blocked to demonstrate it. If this does not block it you continue up the front leg until you are convinced it is not here.

If the horse shows evidence of RR lameness you can start your investigation from there. If the horse shows clear evidence of back pain you can start there. The important point is to keep the diagnostic procedures organized ruling sequential sections of the leg or back one at a time.
DrO
New Member:
cjstumpf

Posted on Friday, Mar 12, 2010 - 2:01 pm:

Hi Dr. O,

That is good logical guidance, thanks! :-) To be clear, I felt the examining vet was careful and professional. However he had family obligations so we had to cut it short. It seemed possible to me that something could be missed under those circumstances by anyone. In addition he had said he would contact me however I was unable to reach him until this morning (just over a week as the exam was 3/4) so it also seemed possible that something had come up.

Since the visit was expensive, the horse is on box rest (which in my experience is appropriate for some injuries but not all), the ICL showed no heat, swelling, or pathology on ultrasound and was previously enlarged, and I had not heard back from the vet as expected, I felt the best course was the follow the vet's orders but also to dig into my homework.

I did speak with him this morning, and he said my notes were accurate and the block he did was specific to the suspensory and did not block the ICL. The location of the needle corresponds to the arrow labeled "high volar block" in the diagram on p3 of the following link: https://docs.google.com/viewer?a=v&q=cache:JsWt-PxSFLAJ:www.cvm.umn.edu/Academics /Current_student/Notes/CVM6420-lame.pdf+%22high+volar+block%22&hl=en&gl=us&pid=b l&srcid=ADGEEShbrHAKmn6ZDUJEqIWVvrw-n9kBfsza8FEMN0MGiF2GmTZRjFdl_O0-PgD6S8KDUpq- zogWM6rVn32L9SXhRyfBXYjOh_7YDslKzGMIb6dq-nL8KGy2hV6JS0nLIdYNeyj1eAMh&sig=AHIEtbS sKjUKYx_Ay9YRVXoIJ0liTwFyTg

and *may* (I am guessing after reading) have been a block of the lateral palmer nerve as described on p165 of Adams https://books.google.com/books?id=MQTRQvwY2MQC&pg=PA165&lpg=PA165&dq=procedure+to +block+the+%22check+ligament%22&source=bl&ots=IGNudyvUU6&sig=cEFVtheUCjaccki2yF5 SOTs4eoI&hl=en&ei=p4aaS8ycNcH88AbE9bigDg&sa=X&oi=book_result&ct=result&resnum=7& ved=0CCcQ6AEwBg#v=onepage&q=procedure%20to%20block%20the%20%22check%20ligament%2 2&f=false

The vet did feel that there was something going on in the back and right hind. However due to his obligations he was unable to look into that area in depth at the time of the exam (and I had no argument with his priorities, this horse is a bit lame not dying :-).

He said he will call me back when he has his calendar in front of him to schedule a re-check, and meanwhile as a backup I have made a clinic appointment Tuesday with a specialist who knows the horses, but is a long haul, so I was hoping not to do that with a possible ligament injury.

Thanks again!
Moderator:
DrO

Posted on Saturday, Mar 13, 2010 - 9:51 am:

As Adam's illustrates there are a number of ways to do a high volar to attempt to block specific structures and both a "low" and "high" high volar are used each with its own strengths and weaknesses. Traditional is the high 4 point which may miss the origin of the nerves innervating the suspensory and there may be some of the ICL missed at its origin but I believe most lameness experts feel that the volume of 5 mls per point will diffuse proximally and include the origins of the suspensory and ICL. The lower high volar would not dependably block the origins but would block most of the distal aspect of these structures. For specific diagnosis of ICL our article recommends, after ruling out more distal structures, infusing the whole area of the proximal suspensory and ICL with anesthetic to avoid any confusion.

As to blocking the lateral palmar nerve and its effects it all depends on the level. If blocked high (before the metacarpal nerves branch off) it certainly will get all the suspensory and ICL as it innervate the distal lateral palmar, the lateral metacarpal, and the medial metacarpal. This block has been referred to as a "Wheat block" and has a lot to recommend it for ruling out diseases of the proximal palmar metacarpus.
DrO
New Member:
cjstumpf

Posted on Monday, Mar 15, 2010 - 2:34 am:

Learning all the medial, dorsal, palmar, lateral terms and their combinations has been interesting. Reading a sentence of Adams with any comprehension takes me about 5 minutes! :-)

I only recall one needle going in though I couldn't vouch for it. Certainly though there were not 4.

Meanwhile a vet who is a back specialist happened to be at the barn doing maintenance on another horse and took a quick look at our patient's leg and back. She didn't get any reaction to the area that previously palpated positive (so maybe that is improving, or maybe since no one had poked at it in a week he's not so annoyed :-) but said his back is quite sore, particularly the right side.

She also clarified something helpful: back and hind limb soreness can indeed cause a nodding lameness, however the head motion is different - the head is thrust more outwards and down in the nod when caused by a hind/back soreness, vs in the front limb soreness where it is more of an up and down motion. Since the indoor was a zoo we could not look at him further. We'll know more on Tuesday!

She also suggested using oil of comfrey on the previously sore area - she said she used to care for barrel horses and they used it on them.
Moderator:
DrO

Posted on Monday, Mar 15, 2010 - 1:31 pm:

I remember attending a seminar where we watched slow motion films of horses on treadmills with confusing head and hip bobs and don't remember us making a distinction as to which leg is lame by the nature of the head bob and just front legs lamenesses can be quite different depending where in the leg the lameness is. But we are beginning to probe the notion of distinguishing different head bobs for different type lameness and maybe this guy has a really good eye.

I think the main point at this time is if you have clinical signs of both rear and front lameness that you consider that there may be one lameness giving both signs and pursue them in a order dependent on whether ipsa- or contra- lateral as explained in the lameness article. As to diagnosing back pain I recommend the article Diseases of Horses » Lameness » Diseases of the Spine, Back & Pelvis » Lower Back Pain in Horses.
DrO
Member:
cjstumpf

Posted on Monday, Mar 29, 2010 - 10:53 pm:

Update:
We took the horse to Mass Equine for a second opinion, where the vet there built on the first exam. The horse presented similarly to the first time despite 2 weeks stall rest and ESWT. The vet watched the horse jog on the tarmac, and on the longe, then did a physical exam. Still no response to hoof testers. He added a palmer block (and reblocked to be absolutely sure) and longed him again. Still off, however as the horse kept going we noticed he longed off on a relaxed jog and pretty sound if we asked for energy, except he would get cranky after a bit and want to turn the other way (this happened both directions).

The vet concluded the check ligament was not a problem at this time though it could have been. He felt toe pain could not be ruled out as it is difficult to block the toe area. He treated his back with injections into the acupuncture points, suggested some trimming changes along with shoes or boots if the horse got very sore, as the horse is pretty flat soled, and sent us home with orders to return to work as the horse tolerated.

The trimming changes were on target, and the horse clearly appreciated the hoof boots after the trim when on pavement or concrete (sabre sneakers with cushy pads), however didn't resolve the lameness.

The horse continued to be off and was opposed to being saddled or mounted. He restricted his own activity. He did initially appear to get some relief from the back injections but his back got worse again.

We finally, after he tried to bite someone and threatened to kick me, both times when I was touching his lower back, did an amateur adjustment on his back followed by "cat stretches" and he jogged off sound and kept wanting to jog. I had to leave that afternoon on a trip.

So, it is too early to tell if this resolves the problem but it was an interesting data point. I passed this information back to the vet, he said what we did could have had some effect on the SI area and muscles in that area. I will post again in a few days.
Member:
cjstumpf

Posted on Friday, Apr 9, 2010 - 11:51 pm:

In my previous post I mentioned that our amateur adjustment of his SI area and some "cat stretches" immediately resolved the puzzling RF lameness, and that I'd post again about whether it lasted.

I returned from my trip to find that the "fix" had not lasted, but we were able to repeat the process and the horse again appeared sounder afterwards.

I don't know whether the back pain is coming from hoof pain or whether it's the core problem (no pun intended). We are trying to schedule a chiropractor before I have to haul north. If I find anything definitive I'll post again.
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