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  Discussion on Calcification next to extensor tendon above knee
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Member:
frances

Posted on Sunday, Apr 1, 2012 - 2:42 pm:

My horse, although sound and forward-going in walk, has become lame in trot. The vet localised the problem to the extensor tendon sheath above the front right knee, and discovered a hard abnormal lump, a calcification, slightly to the medial aspect of the sheath.

In order to soften it with heat, she has had me apply Absorbine with PENNSaid as a carrier once a day, bandaged on and left for an hour. After a week, she assessed it, and said that it hadn't changed at all.

She plans to inject cortisone subcutaneously on Tuesday in the hope that this may "melt" the calcification. Do you feel this is likely to work, and/or do you have any other suggestions for breaking it up?

I have heard of a mixture of heparin and DMSO being painted on in similar cases. And I've read that ultrasound therapy can also be used. Your thoughts on those treatments?

Many thanks for any advice. The vet tells me that if the calcification remains, my horse should only be walked from now on, as the presence of the lump will stretch the extensor tendon at any other pace.
Moderator:
DrO

Posted on Monday, Apr 2, 2012 - 7:55 pm:

Hello LL,
Which of the extensor tendons above the knee is implicated? It may be possible to surgically remove it. This would be an unusual cause for lameness as the extensors on the front are minimally used during weight bearing how was the localization done? There primary job is to advance the leg during the nonweight bearing phase of the gait. How does the veterinarian think the calcification is causing pain?
DrO
Member:
frances

Posted on Tuesday, Apr 3, 2012 - 2:07 am:

She hasn't told me which one but I will ask her today.

The left front lameness first became evident in January and my usual vet (not this one) localised it by watching the mare trot on the lunge, performing a flexion test (knee was fine), using hoof testers on sole and frog and palpating the area above the knee. The vet concluded it was the extensor tendon sheath but did not mention a calcification. She appeared to get much better with treatment (first continuing the cold therapy we had already begun, and then heat therapy, along with handwalking. This vet is now based quite far away, so we consulted over the phone and when I told him she seemed much better, he gave the go-ahead to very gradually start work again.

I took it very easy as she's about 24 years old now, so we were basically just walking and trotting, but gradually the unevenness in trot reappeared. I asked the second vet, who is much nearer, to have a look at her. From watching the mare on the lunge she said left front (which hadn't been all that clear this time around as she'd been resting the RH quite a lot more than usual). I then explained to her about the previous extensor tendon diagnosis, and with the mare's knee flexed she found and showed me the hard lump which she said is definitely abnormal.

She said the lameness is not caused by pain but is mechanical, as the calcification interferes with the advancement of the leg. This seems true to me, as the mare is actually keen to trot, which would be odd if trot were causing pain.

I'm not sure that surgery would be an option at her age - unless it were done standing?
Member:
frances

Posted on Wednesday, Apr 4, 2012 - 1:11 am:

It's the extensor tendon carpi radialis. The procedure was carried out yesterday. The vet first drained plentiful synovial fluid, and then injected a mixture of cortisone, hyaluronic acid and an antibiotic. She applied a pressure bandage which was to be left on for a few hours but removed last thing at night so the mare could lie down.

The vet felt pretty optimistic that this would work and the calcification would be dissolved, although she said there might be a recurrence of edema after a few days as the body replenishes what has been removed.

For the time being, I'm to continue with the Absorbine and PENNSaid wrapping and very light handwalking for the first two days.
Moderator:
DrO

Posted on Sunday, Apr 8, 2012 - 2:21 pm:

Good luck LL, it seems a reasonable course. Since there was synovial fluid it must be near its attachment where the tendon has a synovial sheath. We have a labelled image of this area including the tendon and its sheath at HorseAdvice.com » References » Equine Illustrations » Muscoskeletal Anatomy and Conformation » Knee (Carpus): skeletal and superficial anatomy.
DrO
Member:
frances

Posted on Friday, Apr 20, 2012 - 9:24 am:

An update: 10 days after the aspiration of fluid and injection of cortison, hyaluronic acid and antibiotic, the fluid had returned and lump was present.

Vet feared it must be a bone spur, and two x-rays were taken: fortunately, there was no sign of a bone spur or chip, so the conclusion was that the lump was formed by hardened synovial fluid. Vet said she would discuss with colleagues the best means of softening and dissolving it.

With her consent, I decided to consult my usual (further away) vet, who has treated my horse for many years.

He performed an ultrasound today, and found an adhesion between the extensor tendon and its sheath. He said that normally surgery would be the solution, but not a good idea of course at her age. So I'm to apply cold therapy twice a day, whether in the form of PENNSaid, ice pack, cold hosing, Ice Tight, Surpass, whatever, and continue hand walking daily, report to him if there is any increased swelling, and in any case call him in a few days to see if there has been an improvement and what we do next. I asked what the chances are of breaking the adhesion in this way, and he said the attachment is very thin so it's possible.

Any comments, DrO?
Moderator:
DrO

Posted on Saturday, Apr 21, 2012 - 9:12 am:

Not seeing what your vet saw LL, I will just have to say what he says sounds possible but I am a bit confused as to what you are saying. Is it the adhesion that is causing the swelling or is the adhesion associated with a swelling (outpouching?) of the synovial sheath of the tendon?
DrO
Member:
frances

Posted on Saturday, Apr 21, 2012 - 11:36 am:

Hmm, good question, and one which I will ask him. Thanks, DrO.
Member:
frances

Posted on Saturday, May 12, 2012 - 3:11 pm:

It would seem to be the latter, the "outpouching" of the synovial sheath. Is that a better or worse scenario?
Moderator:
DrO

Posted on Tuesday, May 15, 2012 - 9:37 pm:

I would think most often better.
DrO
Member:
zbgirl

Posted on Monday, Nov 11, 2013 - 10:54 pm:

I am wondering if your horse is sound now. My own horse has something 'similar" and my vet was not so convinced this was the cause of his lameness.
Member:
frances

Posted on Wednesday, Nov 13, 2013 - 10:10 am:

Hi ZBGirl,

Not completely sound I'm afraid. Every so often the area above the knee becomes puffy, sometimes with a little heat but not always. A few days of handwalking, possibly with bute if it seems called for, usually brings the swelling down, but the tendon is never entirely flat. She tends to point that leg now and then, and as she also stretches the opposing hind leg forward once in a while due to some stiffness in her back, I wonder if there is some referral going on there.

She's 26 (at least) now, and ridden mostly in walk, but sometimes produces some nice trot work.

Good luck with your horse.
Member:
zbgirl

Posted on Friday, Nov 15, 2013 - 1:04 am:

My vet has been quite vague in our lameness diagnosis and your post sounded much like our soft tissue injury issue. Similar location but more toward the muscle than tendon sheath, not a fluid filled cyst, but very firm and hard. What is interesting is the fibrous muscle fibers both above and below it. I have been massaging them and now the area above and below are softening up and feel less tight and less stringy. Meanwhile the original lesion has reduced in size and not quite as firm. We are in rehab program so the area is being loaded progressively. I am hoping the adhesion or lesion will just "be" so long as the load on the tissue is ok. He is sound right now.
Member:
frances

Posted on Friday, Sep 19, 2014 - 10:00 am:

Another vet took a look at my horse's extensor tendon today, and was perturbed to see that the joint doesn't close any more when the knee is bent. He said it will only get worse. Exercise is good, and he recommends cold therapy before and after exercise, and heat therapy in the evening. (Don't know if he realises that she stays out in her paddock at night, but I don't think that would matter?)

The reason I had asked him to look at the leg is that the swelling has spread so that it is more swollen around the sides and less so at the front. Some days it is worse than others, and the leg is pointing. Other days it's much flatter (tho' never actually flat)and she is comfortable.

I basically ride her on trails (30 - 40 minutes), mostly in walk with occasional forays into trot when she seems up to it. Every so often I lunge her in the arena and more often than not she takes off bucking, galloping and calling out, which nearly gives me a heart attack, but USUALLY does not result in lameness the next day, but some improvement. According to the vet who saw her today, this letting off steam is not a problem, but lack of motion is.

The leg in question often gives way for a fraction of a second: usually she recovers her balance but once in a while she goes down, knuckling over her pasterns and causing some injury to the skin there.

I would really appreciate your assessment of this situation DrO and the route I should be going so as not to make matters worse, yet to keep the mare fit (and calm, as she's quite spirited).
Moderator:
DrO

Posted on Friday, Sep 19, 2014 - 4:04 pm:

Hello LL,
I am uncertain what you mean by "the joint doesn't close any more when the knee is bent". When the knee is bent the joints normally open up in the front.
DrO
Member:
frances

Posted on Sunday, Sep 21, 2014 - 1:14 pm:

Actually it's probably my mistake: he lifted the lower leg, bending the knee, and found that the leg did not go very high at all. So when he said "it doesn't close at all", he was referring to the angle formed by the raised lower leg towards the upper leg.
Moderator:
DrO

Posted on Saturday, Sep 27, 2014 - 9:50 am:

Hello LL,
The last report of a radiograph was two years ago, has a study of the carpus been done since then?

In general, it sounds like your horse has worsened under the exercise routine you were using so the amount of forced exercise (riding, lunging, etc) needs to be reduced significantly. How long, how much and what conditions would best be addressed by someone who can examine the horse and your horse's response to the prescribed work load. Also an important consideration is the risk of stumbling with a rider.
DrO
Member:
frances

Posted on Tuesday, Sep 30, 2014 - 9:01 am:

Thanks DrO. I've arranged for the vet to take an x-ray, which he agrees is a good thing to do. But he also added that the knee will only get worse, and will get worse faster with insufficient exercise.

All a bit depressing....
Member:
frances

Posted on Sunday, Oct 5, 2014 - 8:50 am:

The radiograph showed no signs of calcification but did show very abnormal posture of the leg. The vet was very concerned, having seen something similar once before, and said that eventually the knee will freeze into a permanently bent angle.

He wants her to exercise as much as possible to keep the joint moving. This sounds to me as if it might exacerbate the inflammation?

He believes that there is a salve which softens and elasticises tendons and might be helpful in this instance, and is trying to recall its name. One of the ingredients is heparin. Does that suggest anything to you DrO?

I will post the radiograph when I get it.
Moderator:
DrO

Posted on Sunday, Oct 5, 2014 - 9:46 am:

Hello LL,
I do not see a dignaosis...what is the abnormal posture he is talking about? A salve that softens tendons? If the recommendation leaves you with questions, have the radiographs sent to a orthopedist for a second opinion.
DrO
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