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Discussion on Fetlock sprain
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Member:
Caymie
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Posted on Friday, Sep 15, 2006 - 8:42 pm:
Hi Dr. O.,
My horse had been diagnosed with a right hind fetlock sprain. He goes sound with an intra-articular block. He is much worse in the soft ground than on hard ground. The lameness is much more obvious when he is circling to the left, when the right hind is on the outside of the circle (they graded him a 3+ in the sand). You don't see any lameness when he is circling to the right, but you can see it on the straightaway, (but it's not as bad as when he circles to the left). His radiographs are clean, as was the ultrasound. He is on stall/run rest.
How long do these types of injuries take to heal?
How long would you keep the horse on Bute? He is improving with rest so I take that as a positive sign.
Thanks,
Mary
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Moderator:
DrO
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Posted on Sunday, Sep 17, 2006 - 7:18 pm:
It is a positive sign Mary. Sprains can vary remarkably in severity and the mildness does not always mean a short course. To determine the prognosis and treatment it will depend more on the tissues involved and lesions present. However the clean radiographs and ultrasound suggest things should be better fairly quickly. You should follow your veterinarians advice on treatment in general anti-inflammatories are used as long as signs of inflammation exists plus about 3 to 7 days.
DrO
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Member:
Caymie
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Posted on Sunday, Sep 17, 2006 - 11:44 pm:
Dr. O.,
Even though the radiographs and ultrasound were clean, he was very lame in the sand. They almost graded him a four going to a circle in the left. Would it be unusual for it to take several weeks to fully heal? Do you ever recommend injecting the joint in situations like these, or is better to just continue with the rest to ensure that it fully heals and he doesn't start back to work to early?
Thanks,
mary
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Moderator:
DrO
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Posted on Monday, Sep 18, 2006 - 6:32 am:
If it is blocks out in the joint within 5 minutes of injection Mary, I always assume there is a synovitis / arthritis component and usually do inject the joint, see the article on arthritis for specifics. If it takes longer than 10 minutes to block our I begin to suspect periarticular structures.
Many causes of temporary lameness take longer than several weeks to get well.
DrO
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Member:
Caymie
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Posted on Monday, Sep 18, 2006 - 8:05 am:
Dr. O.,
That is interesting, I guess if we are dealing with a synovitis/arthritis, he should rest for a few weeks anyway. He did have surgery in this joint about a year and a half ago to remove a chip at the back of the fetlock joint. We have an appointment with the vet today, he has been resting for four weeks, so we'll see how he looks.
Mary
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Moderator:
DrO
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Posted on Tuesday, Sep 19, 2006 - 6:47 am:
Rest is almost always indicated for acute lameness of any type. That is not just interesting but increases the chance of an inflammatory joint disease.
DrO
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Member:
Caymie
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Posted on Tuesday, Sep 19, 2006 - 8:12 am:
Hi Dr. O.,
My comment about being interesting was regarding your information about the joint block and time frame for determining where the pain is coming from
Does the fact that he had surgery in that joint increase his chances of getting inflammatory joint disease? It was a proximo/plantar fragment that was removed from the medial side of the back of the joint. So he could be having an acute flare up even though there are no radiographic/ultrasound changes?
Thanks,
Mary
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Moderator:
DrO
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Posted on Tuesday, Sep 19, 2006 - 6:22 pm:
Yes.
DrO
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Member:
Caymie
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Posted on Tuesday, Sep 19, 2006 - 7:37 pm:
Dr. O.,
OK, well we're going to try some IRAP injections to see if that helps him. He is now very mildly lame, so there has been improvement. However, it would be nice if we could minimize future flare-ups. This joint has been injected with Triamcinilone/HA in the past. Have you had any experience with the IRAP injections? If so, what do you think about their effectiveness? We are doing this through Colorado State University.
Mary
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Moderator:
DrO
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Posted on Wednesday, Sep 20, 2006 - 8:48 am:
This gets even more interesting. Dr McIlwraith from Colorado State, and certainly one of the most knowledgeable persons on arthritis in the world, presented this as experimental therapy in a conference this last December. IRAP stands for Interleukin 1 Receptor Antagonist Protein but I know it better as IL-1ra protein. Here is what is in the notes on that lecture:
Proof of principal experiments demonstrating in vitro expression of an active equine IL-1ra protein after gene transfer of the equine IL-1ra gene sequence to cultured equine synoviocytes using an adenoviral vector were first performed. After confirmation that the adenoviral vector could infect equine synoviocytes and produce a biologically active IL-1ra protein, an in vivo dose titration study was done. Using the same adenoviral vector carrying the equine IL-1ra gene (AdeqIL-1ra), the optimal vector concentration to provide peak concentration and duration of IL-1ra protein expression was determined without notable adverse effects. Next, using our established experimental model of equine OA, this gene therapy treatment was tested and shown to notably reduce lameness and synovial effusion in the arthritic/fragmented joints. The horses receiving gene therapy also had notably less pathologic change seen on gross examination of the joints compared to placebo-treated arthritic/fragmented joints. Microscopically, there was also notable improvement in the articular cartilage compared to the controls. Since our studies, gene therapy with IL-1ra, combined with IGF-1, has been tested for its capability of improving cartilage healing (discussed later). Gene therapy protocol using BMP-2 has been shown to aid healing in the presence of osteomyelitis in rabbits.
This is experimental therapy, what have they told you about the treatment? I am specifically interested in:- Case study results
- Are they injecting the protein or adenovirus vector to express the protein?
- Is this a commercial product?
DrO
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Member:
Caymie
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Posted on Wednesday, Sep 20, 2006 - 9:24 am:
Hi Dr. O.,
Bear with me, as my understanding of how all this works is very primitive. The way I understand it is that the production of the IL-1Ra (interleukin-1 receptor antagonist)blocks interleukin-1 proteins that are associated with joint inflammation and acceleration of deterioration of tissue. They think that these injections can actually stop arthritis from progressing, or possibly even prevent it from developing in the first place in some cases. My understanding is that this is different from IRAP gene therapy, where a virus is used to deliver a gene to the damaged joint. To my knowledge, that has only been studied in vitro. With the IRAP injections, blood is drawn from the horse in a syringe that contains specially prepared glass beads that stimulate the white blood cells to produce the IRAP and anticoagulation. The syringe is spun in a centrifuge to separate the IRAP from the blood and separated into doses. The IRAP is frozen and stored. You typically get several doses from each syringe. The serum is then injected into the joint, usually for three treatments approximately a week apart. You have to have the right type of centrifuge in order to be able to offer the procedure. There was a study done by Drs. McIlwraith, Kawcak and Frisbie of the Equine Orthopaedic Research Center here at CSU entitles: " Evaluation of Autologous Conditioned Serum Using an Experimental Model of Equine Osteoarthritis." There is also a website for the German company that developed the procedure: equine-irap.com.
I have opted to try this as the idea of trying to restore the joint environment via the body healing itself is appealing to me. If this is going to be an ongoing maintenance issue, I would rather use these injections than continued use of a steroid in a high motion joint. In some cases, these injections have eliminated the use of steroid injections altogether. However, I am sure that not every case is going to respond. One interesting thing they are finding is that some horses who have not responded to traditional intra-articular therapy, are responding to the IRAP injections.
The IRAP injections are available commercially, you just have to have the special centrifuge. The blood can also be drawn and the harvested injections frozen and sent back with a horse, if you had to refer the horse to a facility that does this procedure. They typically give three injections before determining whether there has been any clinical benefit. They are pricey little injections. I think that the kit (containing the syringe with glass beads)alone runs somewhere between four and five hundred dollars, and then the cost of each injection on top of that. So somewhere around eight hundred dollars. My horse was trying to be helpful, we actually got six doses out of his harvest, so we can freeze any that we don't use for future use. However, if this really seems to help him, I may have them give him one a month. I have a friend whose horse has really been helped by them and she gives him one a month.
He just received his second injection yesterday.
They did originally inject his fetlock with steroid/HA when he was so lame. However, out thought is that he was not given sufficient rest along with it, therefore it was only temporarily effective. So now we are trying this. With rest.
Pretty interesting stuff-I am anxious to see whether it does my horse any good. Since we know he had surgery in that joint, and nothing is showing up on the radiographs/ultrasound, we are not sure what is going on in there. He is obviously having some type of acute flare up. The surgeon said there was minimal cartilage damage at the time of surgery. I guess there could be something going on in the front of the joint as well, but I am more suspicious that it is somehow related to his surgery.
Mary
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Member:
Sunny66
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Posted on Thursday, Sep 21, 2006 - 11:19 am:
Hi Mary, I'm sorry to hear about your horse, but it sounds like you are on the cutting edge!
I am intrigued about this new product. Would you mind terribly giving us updates on your horse after using this product?
I assume this only works for arthritis in the joint, not spurs?
Thank you very much!
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Member:
Caymie
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Posted on Thursday, Sep 21, 2006 - 1:31 pm:
Hi Aileen,
I would be happy to keep you updated. My horse is lucky that I happen to live very close to Colorado State University!I am anxious to see whether these injections help my horse. Unfortunately, patience is required on my part as you have to wait until the series of injections is completed to assess the effectiveness. I will see the vet on Monday for his third injection and I will inquire about the spurs.Where is the spur in question? I know they have seen some pretty dramatic improvement in a horse with a really bad stifle, so I don't know if it is limited to arthritis or not. And I'm sure that the response is variable. We have our hooves crossed that Caymann will be helped.
Mary
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Member:
Sunny66
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Posted on Thursday, Sep 21, 2006 - 2:45 pm:
Oh thank you Mary!
I know all about needing patience, I need to find some myself! Here is a pic of his stifle, I've circled in red where I think the vet said the changes were in the stifle:
The hock spur is on the front/middle of the lower tarsus, small, and in a good place, if there is such a thing. Both stifle and hock changes are on the left hind.
I checked Brave yesterday and I believe he was 1 out of 10, his stifle looked funny, sliding out behind him. My next step is to rehab his stifle to get him muscled up, if that doesn't work, I will be pursuing other avenues... so I truly appreciate your input Anything that stops djd is worth any amount of money, as far as I'm concerned
Wishing you luck on this!! I hope this helps your boy
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Member:
Caymie
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Posted on Thursday, Sep 21, 2006 - 2:53 pm:
Hi Aileen,
Does your vet have access to these injections? They might be able to give you some feedback as well. I will be sure to ask about spurs in the hock and stifle. There is a website equine-irap.com if you are interested in additional information.
Mary
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Member:
Sunny66
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Posted on Thursday, Sep 21, 2006 - 3:19 pm:
Thank you so much for the website. My vet is wary of new treatments. I don't know if he's heard of this, but I will certainly print out the study from the website and send it to him.
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Member:
Caymie
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Posted on Thursday, Sep 21, 2006 - 3:51 pm:
Aileen,
This is a fairly new treatment and I think probably more effective for some horses than others. I'll keep you posted and will email you after our appointment on Monday.
Mary
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Moderator:
DrO
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Posted on Friday, Sep 22, 2006 - 7:17 am:
One correction to your pathogenesis. The product does not prevent the production of Il-1 but blocks the Il-1 receptors and reduces inflammation this way. However this is not the only way inflammation is created in a joint so it does not cure it but slows its progress.
Modified viral gene therapy for the delivery of Il-1ra protein has been used in both animal (including horses) and human experiments. See the notes above for the results of experiments in horses. Do to the lack of large clinical studies this is experimental therapy but at least with the technique as practiced above looks very promising.
DrO
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Member:
Caymie
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Posted on Friday, Sep 22, 2006 - 7:22 am:
Dr. O.,
I was not aware that the gene therapy has been used in animal and human experiments. I will read over your article again.
He gets his third injection on Monday, so we'll see what happens after that.
Mary
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Member:
Canter
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Posted on Friday, Sep 22, 2006 - 2:52 pm:
Mary, thinking of you & Caymann...& wishing you good luck with this therapy!
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Member:
Caymie
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Posted on Friday, Sep 22, 2006 - 3:31 pm:
Hi Fran,
It's never the easy answer with my beloved horse. I am encouraged by the fact the radiographs and ultrasound are clean. I suspect we have some low grade joint inflammation/damage as a result of his surgery. Since we didn't quite catch it in time, we ended up with an impressive acute flare-up. The vets at CSU that we are working with have seen these injections really help some horses. Hopefully mine will be one of them. Hope you are having fun with Miss Sparkles!
Mary
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Member:
Caymie
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Posted on Monday, Oct 2, 2006 - 9:27 pm:
Hi all,
Just wanted to give you an update. My horse's fetlock sprain has totally healed. He just needed some rest. He had three IRAP injections. I do think they helped him, but it is possible that he may have healed on his own with just the rest. But since he had surgery in that joint, I think it was a good idea to try them. He is starting back to work this week. Just in time to enjoy the perfect fall riding weather.
Mary
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Member:
Canter
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Posted on Tuesday, Oct 3, 2006 - 7:41 am:
Good news, Mary! Enjoy the great outdoors and tell Caymann to behave himself. No more injuries!
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Member:
Caymie
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Posted on Tuesday, Oct 3, 2006 - 8:15 pm:
Thanks Fran. We'll do.
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Moderator:
DrO
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Posted on Tuesday, Oct 3, 2006 - 9:52 pm:
Mary without a clear indication of why was it the treatment or the best doctor of all: time? you don’t mind can you tell us what the cost of the therapy was?
DrO
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Member:
Caymie
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Posted on Wednesday, Oct 4, 2006 - 9:14 am:
Dr. O.,
I suspect that it was Doctor time that healed his fetlock. However, I know that the IRAP injections are used for acute synovitis in some cases. And believe me, he had a raging synovitis, I have never seen him that lame on his hind end. We also had the added complication of knowing that he had surgery in that joint a year and a half ago. I wanted to try the IRAP because I did not want to put any more steroid into that joint. It had been injected with Triamcinilone, but because he did not get the rest he needed, it did not last for very long. I guess you could call it the covering all bases approach. There was a decrease in the amount of swelling in the joint after the first two injections. And, from what I have been told, they think the IRAP injections can stop a traumatic arthritis from developing/proceeding to something more permanent.
The cost of the kit is almost five hundred dollars, and then you have the regular cost of each visit for the injections. Total: approximately eight hundred dollars. Not cheap.
Mary
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Member:
Caymie
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Posted on Thursday, Oct 5, 2006 - 7:43 pm:
Hi Dr. O,
One additional question I forgot to ask. Does a horse with a fetlock sprain always have swelling in the ankle area? I was just curious because my horse didn't have a whole lot of obvious swelling, just some increased joint effusion mostly and maybe some puffiness around the tendon sheath. I guess an easier question would be: can you have an ankle sprain without a lot of swelling?
Thanks,
Mary
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Moderator:
DrO
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Posted on Friday, Oct 6, 2006 - 7:59 am:
The term "sprained fetlock" is almost without any real diagnostic meaning Mary. Yes it represents a localization and even perhaps a suggestion of pathology, acute soft tissue strain, but when you consider the number of possible structures in the fetlock area that could be strained the term becomes almost meaningless. Yes there are some structures in this are that if strained may show minimal swelling, for instance I have seen some reports of deep digital flexor strain within the sheath has been reported to be "occult". But the point should be when presented with such a situation, and if it is your goal to get a accurate diagnosis and therefore institute the best treatment plan and get a reliable prognosis, you should pursue it with advanced diagnostics.
DrO
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Member:
Caymie
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Posted on Friday, Oct 6, 2006 - 7:14 pm:
Dr. O.,
He was ultrasounded and radiographed with no significant findings. No findings at all really. So, could the reason he looked so much worse in the sand be because of a synovitis or capsulitis type problem as opposed to a bony problem? What types of soft tissue problems could be present intra-articularly? Just wondering.
Mary
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Moderator:
DrO
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Posted on Saturday, Oct 7, 2006 - 11:37 am:
I discuss this in the Sept 18th posting above. Also important is to realize radiographs do not rule out early osteoarthritis, see the article on interpretation of radiographs for more on this.
DrO
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Member:
Caymie
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Posted on Monday, Oct 9, 2006 - 10:43 am:
Dr. O.,
Well we certainly had a raging synovitis, that's for sure. I am hoping that with the several weeks of rest and the injections that we have headed it off at the pass. Time will tell, but I am glad that the radiographs didn't show anything too scary.
Mary
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Member:
Caymie
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Posted on Monday, Nov 27, 2006 - 7:23 pm:
Hi Aileen,
I wanted you to know that I have not forgotten about your hock/stifle question and the IRAP injections. I will probably have a better answer for you in a few months. My horse too has mild arthritis in his right hock and stifle. (He had OCD surgery in his stifle when he was almost five). We are going to try the IRAP injections in his stifle starting in January to see if they help. I think what helped his fetlock most was the rest and the intra-articular HA injection. But he had no radiographic changes so it's hard to say. I'll keep you posted. Some of the vets at CSU have told me that they have seen some pretty significant improvement in horse's stifles that are in much worse shape than my horse's.
Mary
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Member:
Sunny66
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Posted on Tuesday, Nov 28, 2006 - 10:50 am:
Thank you so much Mary. He has stopped the weird action in his stifles, and was in good work for almost 3 weeks (20 minutes trot), now we have other issues, however.
I am very curious to see if the IRAP helps your boy. The way my boy is going, I still may need that eventually. I look forward to your update!
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Member:
Caymie
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Posted on Tuesday, Nov 28, 2006 - 7:57 pm:
Aileen,
We'll keep you updatedHis first injection will be on January 3rd.
Mary
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