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  Discussion on 20 yr old gelding with arthritis
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Posted on Tuesday, May 15, 2001 - 11:41 pm:

Apologies in advance, because this is long!!

I've got a wonderful 20 yr old 16h3 Hanoverian gelding who retired from intermediate eventing at 12 from a mild SDF injury in his LF. His previous owner (a very tactful, expert rider) kept him fit till I was lucky enough to start riding him 3 years ago. He's taught me a tremendous amount, and introduced me to eventing, and we've had a couple of wonderful summers competing at the lower levels. He's always been keen to gallop and jump an x-c course, and show off his beautiful suspension and extension in dressage. He has always looked much younger than his years.

This winter, all has changed. He had a respiratory virus and high fever mid-January. No cough, but he was was very stressed during the illness, and the vet put him on antibiotics in case pleurosy was developing. It took him a good week to start eating normally, but he seemed himself a few days later. We started back to riding very slowly. With 3 feet of snow on the ground, all we could do was walk on the roads. Then, early in March, we managed to get to an indoor for a flatwork lesson; after 15 minutes of good trot work on a large circle going left, he felt short strided on his LF circling right. Had the vet out, and he flexed positive both forelegs (worse in the RF) and from that test and xrays the vet diagnosed lower ringbone (coffin joint DJD). Thinking back, I can recall some instances (as long as 2-3 years ago, and including a couple of warmups for competitions last summer) where he was uneven going right, but he has always worked out of it in the past. Is this how arthritis hits? Seems so sudden! Up until his virus in January, we rode 5-6 times a week and he was raring to go.

The vet prescribed rest and a week of bute, 1g 2x/day, plus 4 weekly shots of Adequan. The rest and bute helped, but he hasn’t returned to soundness at work without the bute. He’s been on Grand-Flex for the last 2 years; I switched him to Corta-Flx but don't see any improvement. He's also getting an HA shot 1x month. He's had the same (expert) farrier for more than a dozen years (has had eggbars for navicular changes since the age of 8; farrier added slight wedge pads at the ringbone diagnosis). He's turned out 12-14 hours a day on grass, nothing hard. Up to now, he's never been sick, lame, or otherwise unhappy.

The suddenness prompted me to seek a 2nd opinion, though I very much trust my 1st vet and have no doubt there is some arthritis in both foreleg coffin joints. Question for me is whether there is something else that's either contributing to the problem, or that has compromised his ability to cope with something that must have been brewing for a long time. The 2nd vet, also someone I trust, flexed all 4 limbs (all positive) and took a Lyme titre; also gave him acupuncture, some chiropractic, and an HA shot all or some of which seemed to help. The Lyme test came back equivocal (Elisa 459, western blot 3 faint bands), so we treated him for that (had to switch antibiotics to SMZ/TMP when he immediately colicked on the Doxy). Did the 2 weeks of SMZ/TMP plus probiotics, then Ledum 1m, plus Lyme Supplement from ABC, but he's no better. Also had dental work done including incisors by a very qualified dentist. Got him a new (used) dressage saddle that fits very well, better than the last one which needed a pad. Gave him some more time off.

Took him back to the 2nd vet for followup a week ago, she flexed him again and that RR flexed very positive. Injected both hocks. He was pretty quiet for 3-4 days, but is back to galloping around his pasture when he finds a reason to celebrate. But from a work perspective, he's still off -- still seems sore on that RF.

He's lost a lot of muscle, particularly topline and hips and neck, definitely aging from this ordeal and/or loss of regular activity. I don't think the loss of condition is helping him cope, so I'm struggling with what the right exercise/management routine is to improve his condition without hurting him. I lunged him a little today on a big circle (first time I've lunged him, but he's an old pro at it) thinking maybe I should build him up again slowly without me on his back (am I the problem??) but I still see a faint unevenness at the trot on that RF even on the lunge.

I know I can help the pain with some bute, and I think the acupuncture is worth continuing, but is there anything else I can do for him? By now, I'm reconciled to the loss of my eventing partner and I'm beginning to think dressage may be out too, at least from a competitive standpoint. I'd be grateful for any insights or suggestions!

Thanks, Melissa

Posted on Wednesday, May 16, 2001 - 9:00 am:

Melissa,
You never state whether the second vet agrees with the diagnosis of ringbone?
DrO

Posted on Wednesday, May 16, 2001 - 11:37 pm:

DrO,

That's a very good question. I don't think the 2nd vet doubts the xray evidence (lower P2 changes are clear). But, a month ago, I'd say the 2nd vet wasn't sure whether we were dealing with arthritis only, or arthritis with some aggravating condition (like Lyme) which might explain his overall soreness and the positive hind-end flex tests.

By last week's visit, the 2nd vet had ruled out Lyme as a cause of arthritic symptoms (due to the lack of response to antibiotics), but thought the horse was suffering more from hind end pain than forelimb pain after performing more flex tests and seeing the horse lunged again.

I think the 2 vets have very different styles. The 1st vet is very quick and direct with diagnoses, and the 2nd vet (perhaps because it's a 2nd opinion?) is exploring possible alternatives. Perhaps the 2nd vet is trying to find us a "loophole" of hope with respect to the ringbone diagnosis. From what I've read, the prognosis isn't very good.

That said, I should just mention that the 1st vet said his diagnosis was based on the combination of the lameness and the xray changes. He said my horse's changes weren't "horrible", and that he'd seen worse changes in a sound horse and better xrays in a lame one. But I don't think he had any second thoughts about his diagnosis.

Thank you,
Melissa

Posted on Thursday, May 17, 2001 - 10:36 am:

Hello Melissa,
Has no one used any nerve blocks to help better localize the lameness. At least it would differentiate foot lameneness from any other issues. The purpose of all this gets back to your original question, "what else can be done?". To answer this question requires a good diagnosis.

As to what can be done for ringbone (DJD of the the middle phalngeal or/and distal phalangeal joints) I would study the article Equine Diseases: Lameness: Diseases of Joints : Arthritis and DJD: An Overview.
DrO

Posted on Thursday, May 17, 2001 - 9:57 pm:

DrO,
Thanks for your reply. The article is excellent, and I'm re-reading. I agree nerve blocks could help solidify the diagnosis, and will pursue this. What is your feeling about injecting the coffin joints with HA/steroids if the forelimb ringbone is confirmed?
Best,
Melissa

Posted on Friday, May 18, 2001 - 7:00 am:

If the radiographic changes are mild, the inflammation fairly acute, and the joint environment not so poor that DJD is inevitable, it may make a remarkable difference. If you truly have chronic osteoarthritis of the coffin joint, it will help for a period but the lameness will return.
DrO

Posted on Monday, May 21, 2001 - 1:15 pm:

DrO,
Thanks for your reply. Two more questions:
1) The first vet diagnosed DJD, so this would be a chronic case, right?
2) Do injections damage the cartilage, i.e. help short term but accelerate DJD long term?
Thanks,
Melissa

Posted on Tuesday, May 22, 2001 - 7:01 am:

1) yes
2) The answer to this question depends on:
  • a) the health of the joint
  • b) what, how much, and how often it is injected

While "b" is self evident "a" may need to be explained. It is probably more harmful than good to inject perfectly healthy joints with anything. However if a joint is inflammed medications designed to relieve that inflammation is probably more good than bad.
DrO

Posted on Wednesday, Jun 20, 2001 - 8:22 pm:

Dear DrO,
One other thing I've noticed and am wondering about: my horse has a dent (muscle atrophy?) in the right side of his neck below what I am told would be C6. C6 has also required significant adjustment according to the vet/chiropractor. No other atrophy signs. The vet said EPM could localize, or it could be nerve damage from an injection, or ??? The dented area is like a shallow dip, runs horizontally, maybe 4-5" long by and a couple of inches, lying maybe 4-5 inches below the top of the neck. Not quite parallel to the neck line - tilts down a little. Have you seen something like this before?
Thanks,
Melissa

Posted on Friday, Jun 29, 2001 - 7:58 am:

Dear DrO,

I spoke with the 2nd vet about joint blocks. The 2nd vet says we're either dealing with "arthritis only" or with "arthritis aggravated by something else", e.g. Lyme or some other tick-borne agent. Treatment options depend on which it is.

The vet says the joint blocks might give us "more information", but won't tell us which of the two scenarios we're dealing with. There's no doubt that he has arthritis, and there's no doubt he's feeling pain in those front feet. The vets says joint blocks are invasive, and if we're going to invade the joint capsule, better to be doing something therapeutic.

The vet wants to treat for/rule out Lyme before continuing with "arthritis only" treatment options (coffin joint injections, for example).

I know from reading on the site that Lyme is not an established clinical problem in horses, but just about everyone I know here in Massachusetts knows someone whose horse was diagnosed with it and responded to the antibiotics. And we all have human friends who've had Lyme -- it's endemic.

The vet believes horses do get clinically ill from Lyme, has done "hundreds" of titres, and says Elisa titres of 100-200 are more "normal", that a horse with a titre of 460 is a positive, and that post-Doxy, titres come back down into the "normal" range. The vet also ran a PCR, which was negative, but so far has never seen a positive PCR from blood work anyhow in a horse (has seen one positive from spinal fluid).

I'm willing to give the Doxy a try and see if he gets better, but am worried about it because he colicked the first time we tried to start him on a Doxy course. The vet insists the colic wasn't caused by the Doxy -- has "never seen Doxy cause colic", even though the horse had never colicked in his life before, and the correlation seems so obvious to me (went off his feed the morning after the first evening dose, colicked in the afternoon after the am dose). The 1st vet says tetracyclines often cause colic. That's what prompted my other post under antibiotics.

Have you or others reading this forum seen a horse treated with Doxy to some benefit for lameness issues? I know there aren't any good studies yet, but are there cases from practical experience that resemble ours?

I'm worried about causing him to colic, but I don't want to leave out something that could help him. Just a decade ago, human doctors didn't recognize Lyme or other tick-borne diseases in humans, so I figure there's still room for doubt.

Please let me know your reaction!
Thanks very much,
Melissa

Posted on Saturday, Jun 30, 2001 - 1:26 pm:

I really do not have much to add since you know that experimentally horses that are infected with Lyme Disease, shed and seroconvert but do not show clinical signs. This has been attempted many times.

The most intesteing thing is the use of a temporal realtionship to justify the use of the medicine (cure following treatment) but not the possible side effect (colic following treatment). Of course one could point out the reaction only happened in one instance and the other happened in a lot of instances. But we must also realize that well over 80% of acute lamenesses will resolve with time on their own.

I too have used treatments for years thinking I saw a clinical response only to find that research indicates beyond a shadow of a doubt that the medication was not effective, see BULLETIN BOARD: The Lounge: Kick back and relax: Alternative Medicine and Epistomology: DrO's Big Mistake for one such story.

This is the reason why we must be so careful about temporal relationships where other factors are not controlled for: all of history, and medical history in particular, tells us they are not proof or even strong evidence of a causal relationship.
DrO

Posted on Sunday, Jul 1, 2001 - 8:30 pm:

Dear DrO,

Thank you very much for your reply. If we follow the course of "ringbone management", and he seems definitely more comfortable with bute, what is your feeling about long-term bute use? If he's 1250 lb (maybe more -- how accurate can those weight tapes be???!!), what's a therapeutic dose? (The 2nd vet says 1g/day "isn't even therapeutic".)

Also, beyond testing for liver/kidney toxicity tests on an annual basis, how can I help insure against ulcers?

And another question: should I continue the Adequan, the Legend, or both and how frequently? Neither are curative, I know. But I would like to do what's humanly possible to slow down the progress of his DJD.

Oops, one more question, what's your thinking about acupuncture, chiropractic, or any other adjuvant therapies for DJD? I have read your article more than once, but would love "your take" on this special horse, from his history above.

Thank you!!
Melissa

Posted on Monday, Jul 2, 2001 - 8:07 am:

We cover just about your all your questions on medications and ulcers in these three areas:
1) Equine Medications and Nutriceuticals: Anti-inflammatories, Steroids, and Arthritis Treatment
2) Equine Diseases: Colic and GI Diseases: Gastric Ulcers
If after studying these two areas you still have questions you know where to post them.
3) BULLETIN BOARD members only: The Lounge: Kick back and relax: Alternative Medicine and Epistomology

Concerning a special take from the history provided Melissa, there is very little uselful I can add without examining the horse myself, afterall I only know what you tell me. I can guide you on the proper diagnosis and treatment of disease by providing accurate facts and experiences, but cannot make that leap to diagnosing and treating your horse. Anyone who pretends to do so on the Internet is either naive or dishonest.
DrO

Posted on Tuesday, Jul 3, 2001 - 7:46 am:

Melissa,
I find 1 gram of bute to be therapeutic on my arthritic mare(and the occasional 2 grams or 1 gram twice a day makes her almost exuberant because she feels so good). She is rideable but I am working her on the lunge-line so my weight is not a factor. I work in a sand arena and do a really slow warm up. About 10 minutes of walking, then 10 minutes of alternate trot/walk. At the end of the 20 minutes the lameness is virtually unnoticable(and she is very stiff in one fetlock to start out with). She is also on cortaflex and gets a monthly shot of Legend. Her condition, like your horses came on suddenly.
It looks like you have done a lot for this horse with both traditional and alternate treatments. If you'd like to try anything additional, I would suggest some sort of equine massage, focusing primarily around the area that is affected. (example if it is the right front, massage the corresponding shoulder, neck, underline area). I also do passive stretching of the area to reduce stiffness.

Posted on Thursday, Jul 5, 2001 - 10:29 pm:

Jackie,
Thank you so much for your post, and your experience treating arthritis with daily bute. What kind of arthritis does your mare have, and how big is she?
I think you're right about the massage. He does feel stiff in the shoulder, so I tried some foreleg stretches and he really leans back into the stretch! I also started doing belly lifts to relax his back, and he's getting better and better at them. He seems to really enjoy it, so I'm thinking I should try to expand my repertoire.
Best wishes to you are your mare, and thanks again for writing!
Melissa

Posted on Friday, Jul 6, 2001 - 7:23 pm:

Melissa,
I believe my mare has chronic arthritis(DJD) and I had arthroscopic surgery done last October to determine the extent of the damage. The surgeon was actually surprised that she was so lame based on what he found but that's just one of the mysteries you deal with. She improved dramatically at first and is still much more comfortable than before the surgery.
She is not a big mare(Arabian). As far as the massage, I like the Jack Meagher book, Beating Muscle injuries for Horses. I also make sure she is warmed up a little before doing any stretches.
Good luck with your horse. I find it is very helpful to try to do one extra thing at a time so you can see what really helps. Legend and Bute help my mare the most.
Additionally, I sought a second opinion because I felt the initial treatment options placed too much emphasis on her age not her condition nor what I wanted for her.

Posted on Friday, Jul 6, 2001 - 10:10 pm:

Jackie,

Thanks for the additional info. What joint was affected in your mare? I guess a large joint, since you were able to pursue arthroscopy.

My vet also mentioned x-rays don't correlate that well with lameness symptoms. Yes, one of those mysteries.

Thanks for the suggestion on the book, I'll get a copy from our library. I definitely see he's stiffer than he used to be before this all started, so I agree there's an opportunity to help mitigate the discomforts that are secondary to the arthritic pain. Very reassuring to know that bute hasn't given your mare horrible ulcers, etc.

Best,
Melissa

Posted on Saturday, Jul 7, 2001 - 8:44 pm:

Melissa,
My mare's lameness localized to the fetlock. There was obvious thinning of the joint space along with a cyst. My primary vet recommended surgery but when I took her to the university they did not feel she was a candidate(I think based on her age and uncertain results). However I sought a 2nd opinion and had Dr. McIlwraith from Colorado State do the surgery.

I did have nerve blocks done as part of the diagnostic process prior to surgery. However it was obviously the left front so I have the joint injected even before that. It made a difference even though she was already getting Legend injections. In your situation it sure sounds like you need to firm up the diagnosis somehow. Is there some kind of veterinary school near to you where they could spend some time looking at all the different issues?

Posted on Sunday, Jul 8, 2001 - 1:48 pm:

DrO,

I've read the article on bute, and noted the possible side effect of ulceration of the right colon.

I've noticed that off and on my gelding gets very touchy on his right side around the end of his ribs and down towards his abdomen. If I'm brushing him there, he'll raise his RH in a warning, and as he's a perfect gentleman who does not kick, this is a strong signal from him. I mentioned this to my 2nd vet about 6 weeks ago when it was happening; the vet said I was probably just hitting some acupuncture trigger points. This never happened in the past, before the whole arthritis thing started. I've only just started to keep a daily log, so can't correlate different bouts of this with anything in particular.

Anyhow, it's happening again, and I've had him on bute for 10 days (he had what the vet called a "flare-up"). He's had 2g 2x/day for 3 days, then 1g 2x/day for 2 days, then 1g 1x/day for 5 days. In addition to the sensitivity on his right side, he really groaned when he stepped up and out of his stall for the past 4 days (except this morning, when he was extremely eager to go out) -- he has to step up about 9 inches to the aisle. Otherwise he seems normal, and he's been pretty comfortable on hacks too, even offering some trot downhill for a change.

Any reason to be worrying about what sounds from the article to be a much more serious side effect? And any thoughts about this one-sided sensitivity?

Thanks!
Melissa

Posted on Monday, Jul 9, 2001 - 7:46 am:

I cannot comment on whether your horse may be developing serious side effects from the use of bute. They are rare at normal dosages.

Sensitivity to being touched in the flank is very common in healthy horses. Groaning while stepping out of his stall is of unknown significance but I have healthy horses that groan when they stand. Neither of these symptoms by themselves strike me as a indication of disease.
DrO

Posted on Tuesday, Jul 10, 2001 - 9:40 pm:

Thanks DrO. I hope I don't sound too paranoid! This is my first horse, so I worry most about failing to recognize something serious.

I don't think I see a bute reaction. But, I definitely see occasional hypersensitivity on that right side. And that groaning stepping up out of the stall is also unusual and new. One morning recently, he really hesitated before moving that hind end up. But, he hasn't shown this behaviour for the past 3 days...

So, burning question: could it be Lyme. I have read stuff on the web just today about Lyme causing hyperesthesia and also a study about induced Lyme infections correlating to some degree to coffin joint lameness. And, I got the 2nd Lyme test back from Cornell today. The Elisa is down from 450 to 355 -- the lab says >440 = strongly indicative of infection, 110-440 is equivocal; the Western Blot has gone from "equivocal" to "low level of antibodies indicating infection with bB".

So, the vet says time to try the Doxy again. Hopefully, he won't colic this time. If there's any way to mitigate the risk of colic from the Doxy, I'd be so grateful. Given he went off his feed last time in under 12 hours, and was colicking in under 24 hours, any guess where in the GI tract he was suffering? (stomach or colon?) and what (if the Doxy was the culprit) we can do to help him cope with it this time? Vet thinks we should go with the 25 pills 2x/day for the first 2 weeks to make sure he can tolerate it before trying the 50+ pill dosage.

I sure hope it will help him. I have seen all sorts of stiffness in him that could either be the result of trying to cope with the coffin joint DJD or the result of something else. At times his right hind looks stiff. When I ride, I feel something funky in his spine. And then, a different day, he feels better. So maybe there's something to it. Will report back on what happens.

Melissa

Posted on Wednesday, Nov 14, 2001 - 8:01 pm:

Dear DrO,

Here's an update on the "diagnosis" part of my horse's case (treatment questions re NSAIDs are in a separate thread).

The Doxy didn't have any effect on his lameness (and I gave him 40 pills twice a day for most of the program just to make sure we weren't undertreating).

I took him to Tufts for a full lameness workup thinking: "blocks" per your earlier comments. 1-minute flex tests showed 2-2.5 out of 5 on all 4 legs (they even did the lower front joints separately from the knees), and he's got reduced range of motion in the front fetlocks, though his hind end shows good range of motion and his back seems to feel just fine. They see "joint effusion" everywhere, and some tendon effusion at the base of the SDFs in front (what I think of as his front leg windpuffs).

They said we could go one of 2 directions with further tests: either we do a series of blocks (est. $500-600 plus xrays, and not necessarily diagnostic because it's bilateral lameness in both front and back, and in multiple joints); or we do a bone scan (est. $800-1200 plus xrays and some blocks) which will show us all the places where there's inflammation, so more comprehensive.

The chance that we'll learn something that will change our diagnosis (older horse that's worked hard and has arthritis in multiple joints) and/or therapeutic program (low-dose NSAIDs and regular work to keep him comfortable and as fit/flexible as possible)? Less than 20%.

I'm thinking at this point I'm reconciled to the diagnosis we've got and our therapy plan -- unless you think I'm leaving a "stone unturned"!

Thanks,
Melissa

Posted on Friday, Nov 16, 2001 - 6:31 am:

Hello Melissa,
Not being there to examine your horse I am not in the best position to comment but some of what you were told strikes me as nonsense. They estimate the cost of the blocks to be 500 to 600 dollars? Plus the base exam I charge 20 to 40 for uncomplicated nerve blocks and 35 to 50 for intraarticular blocks. The purpose is not diagnsosis but localization.

Tufts should know that the results of their flexion tests are of uncertain significance and if they do think they have found something significant, this should be pursued with either further localization and radiography. They should have told you that without prior localizations the significance of the results of the gamma scan could be unknown as areas of increased uptake of the dye that are not associated with lameness is very, very common.
DrO

Posted on Friday, Nov 16, 2001 - 4:27 pm:

Hi DrO,

Thank you so much for your post. I'm a lot clearer now on what these tests are meant to accomplish.

On the blocks, I think they charge $35 for non-articular, and $50 for articular. They thought it would require a lot of blocks to get a reliable read because it looked to them to be bilateral, both front and back, so multiple joints in all 4 legs. And yes, xrays on top of that -- the blocks would only tell us which joints are the most painful.

Re the scan, they definitely looked at this as a starting point, before any blocks were performed. They said they'd have to do fewer blocks if they did a scan first. And yes, xrays on top of the blocks. They didn't say anything about "false positives". Hm...

They didn't appear to question the results of their flexion tests. They thought these tests confirmed that multiple joints were involved. I confess I found myself thinking I'd be lame too if someone jammed my ankle for a whole minute and then made me trot off.... But I should be clear: they weren't diagnosing from these flex tests -- they were expecting the scan, blocks, and xrays to accomplish that. They expected me to choose whether or not to do a scan. They were fully prepared to do blocks that very day if I'd said NO to the scan.

So, there I was in the parking lot, wincing at how sore my poor horse was without his daily NSAIDs. I'd waited a month for the appointment, and was expecting we'd do a few blocks and xrays and I'd go home $400 poorer but with a firm diagnosis (at last!) and some peace of mind.

Instead, there I was with major sticker shock and a lot of indecision. The scan was so expensive!! But, blocks without a scan were going to come to a lot of money too, and blocks without a scan were presented as an inexact science -- they stressed the difficulty using blocks with bilateral lameness cases (one leg compensates for the other; as you're blocking the second leg the first leg's blocks start to wear off; and we seem to have front and hind leg lameness, etc. etc.).

So, given the choice between a) wildly expensive diagnostic path (probably $1200-1400!!) and b) very expensive and maybe less conclusive diagnostic path (probably $800-1000), that's when I asked the doctor whether I was wasting my money going down either of the paths.

I asked him 2 questions: first, what's the probability that we'll learn something we don't already know? Answer: less than 20%. And second: what would you do if this were your horse? Answer: given the horse's age and career history, his lameness history and what's been tried so far, and how he appears at the exam, if it were his horse he'd be satisfied (as a vet) with a diagnosis of "older horse who's worked hard and has some arthritis in multiple joints". But he said he thought I should do the further tests for my own peace of mind (!).

If there's a real chance we've been missing something that would change our therapy and improve our outcome, I'll willingly pay the price. I want to do what's best for my horse. But if we're just gathering more evidence that my old campaigner is showing his age and the understandable wear and tear of an athletic career, then I figure I may as well put the money instead into some coffin joint injections, continue with the Legend, Adequan, and meclofenamate, and get a 2nd horse for the competitive stuff.

Sorry this is so longwinded. Is there a more reasonable course of action for us?

Thank you so very much!
Melissa

Posted on Saturday, Nov 17, 2001 - 2:12 pm:

Without being there to do the exam, knowing your budget situation, or even your goals at this point, I cannot know what the most reasonable course is for you Melissa.

But you should discuss these with those doing the exam and then apply and enquire about the information we have supplied and together yall should be able to come up with a reasonable course of action.
DrO

Posted on Saturday, Nov 17, 2001 - 2:57 pm:

Thanks, I think I have the info I need now to be a party to that dialogue.
Melissa
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