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Joint Injections and Soft Tissue Injury Treatments

November 2017 - AAEP is on Stall Rest

AAEP is taking the month of November off from "Ask the Vet", but will be back in December to answer your equine health questions concerning winter weather care for your horse with expert, Dr. Christine Tuma.



Click here to read this month's questions and answers.
  1. My 13-year-old mare has arthritis of the c6-c7 neck region and some loss of demarcationand changes in c3-c4. She recently presented with hock issues, which radiographs confirmed. My veterinarian thought it best to inject the hocks, in which I agreed, but have always felt that it is her neck that gives her the most discomfort. She is steady in both front legs but has an intermittent head bob. Should I continue and have the inter articular facets injected or keep her relatively comfortable with medication until that no longer works? We have had to have the muscle injected in the past as it causes inflammation, which helps, butnever goes away.

    (View Answer)

    Sounds like you have undergone appropriate workup and diagnostics to determine sites of possible discomfort in your horse.

    Without evaluating your horse, I cannot tell you what my opinion would be for treatment or injections. Your veterinarian would be the best one to guide you in the decision making process after a complete lameness exam both in hand and under saddle as well as a neurologic examination given the presence of osteoarthritis as you describe at several sites within the neck.

    What I can say is that is it not uncommon to inject multiple sites on the same visit (ie: articular facets within the neck and lower hock joints). The articular facets should be injected under sterile preparation and ultrasound guidance (vs. radiographic or blind) and hock joints can easily be injected after aseptic preparation without any form of imaging. It may also be required to use daily or pulsed Equioxx (Equine specific firocoxib) therapy prior to and during periods of increased exercise/work or longer. Intramuscular injections generally do not work completely for neck pain and may last a short amount of time.

    A good working relationship between you and your veterinarian is imperative to find the right combination of treatment(s) that works for your horse. Keep in mind that this may work for some period of time, but arthritis is a progressive disease and treatment may over time work for a shorter time frame before needing re-treatment or treatment with a different type or course of medication. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  2. I have a very nice barrel horse that I purchased two years ago. It has been a nightmare of an experience. Within five months of ownership, my veterinarian diagnosed her with EPM. She showed all of the symtoms, muscle loss, stumbling, legs buckling and weightloss. I have had sucessfully treated her three times now. It seems every four months she starts showing obvious symptoms. I am curious if this is something other than EPM that the treatment is working on or will I have to keep treating my mare every several months for the rest of her life?

    (View Answer)

    I am sorry to hear about your horses diagnosis of EPM. This can be a challenging disease both to diagnose and to treat and certainly affects their ability to be a performance athlete.

    Without evaluating your horse from a medical and neurologic perspective or knowing what medications your horse has been treated with, it is hard for me to speculate as to how long or how many times your horse may need treatment.

    I would encourage you to get a definitive diagnosis for EPM, if it has not been obtained based on blood AND CSF tap. Also, consider other diagnostics to completely rule in or out other diseases or syndromes that can cause similar symptoms to EPM as recurrence of signs may be EPM or it may be something else on top of or instead of EPM. You veterinarian can discuss these other diseases and diagnostic options with you and it may require you needing to transport your horse to a referral center. In the meantime, keeping your horse comfortable, safe and pain free is the ultimate goal with prolonging the interval between clinical signs as long as possible! Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  3. We use to be told that the joints would fuse at a certain age and there would be no need for injections. True or False?

    (View Answer)

    Your question is an interesting one, thanks for your submission!

    Normal joints, without evidence of osteoarthritis, trauma and/or inflammation should continue to function with normal gliding motion between cartilage surfaces without the need for joint injections.

    Normal joints can become temporarily inflamed secondary to trauma/inflammation. This could be from a bad step, twist, strain, overuse. This cycle of inflammation can be mitigated by joint injections, reducing pain, swelling, effusion (increased production of abnormal joint fluid) restoring the internal joint fluid back to normal color and viscosity.

    If trauma/inflammation is persistent secondary to chronic overuse, cartilage breakdown, supporting soft tissue injury and conformational defects, which leads to improper loading of the joint, the cartilage surfaces start to break down (beginning stage of arthritis), underlying subchondral bone may become damaged which leads to chronic pain and lameness.

    The body then starts to produce new bone in efforts to stabilize the joint. While this is occurring it can be a painful and prolonged process and often times, joint injections help to reduce some of the clinical signs to some extent, but do not resolve the underlying problem.

    Joint fusion can occur naturally, chemically or surgically with the goal being to stop motion between two bone/cartilage surfaces.

    To answer your question, there is no age that this happens in all horses in all joints. In general, advanced arthritis (most commonly- low or high ring bone or bone spavin in the hock (arthritis of the two lower hock joints)), takes a very long time for natural complete fusion to occur, if it occurs at all and is painful during this process. Usually, this type of arthritis is seen in older horses from wear and tear of performance, but can be seen in younger horses secondary to trauma or conformational abnormalities.

    Chemical fusion works by injection of an agent that destroys or melts the cartilage surfaces such that bone on bone remains behind and eventually, over time, these two bone surfaces fuse together. Again, this can be a very painful procedure that takes several months to complete.

    Surgical fusion is a procedure performed under general anesthesia that removes the cartilage surfaces between two bones and uses a combination of plates and screws to stabilize across the joint to allow for healing of the bone ends to one another. Again, this is a painful procedure, with involvement of surgery, but tends to get a more controlled and quicker response to healing due to stabilization of the bones between the joint.

    Out of all of the joints in the horse, the lower hock joints is the most common location that has the possibility to naturally fuse over time. However, the age and time frame is highly variable and dependent on the horse and may require joint injections 1-2 times/year to help reduce inflammation and pain while this is happening. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  4. I have taken on a OTTB horse that was injured six months ago with bone chips in the front knee area. He seems comfortable at a light walk/trot with no heat in the area and no limping. Could you suggest a safe workout for him? Should I wrap the knee? Any feed suggestions? I have never had a horse with this problem but I could not let him go. I see potential in him as a wonderful pleasure horse. Any suggestions would be appreciated.

    (View Answer)

    Thank you for taking in this OTTB and finding him another home and job. Unfortunately, osteochondral fragments in the carpus can be a common injury in the racehorse due to hyperextension of the knee and chronic repetitive/trauma secondary to race training or racing. Typically, arthroscopic surgery, under general anesthesia, is required to evaluate the joint space, remove the fragment and clean up traumatized cartilage. Depending on the location and extent of fragmentation, without removal of the fragment(s) the joint will continue to be traumatized, inflamed and precipitate early development of arthritis within the joint.

    I would encourage you to contact your veterinarian to evaluate the horse prior to initiating any exercise routine or riding under saddle. A complete lameness evaluation, flexion exam and radiographs should be taken to evaluate the joint and carpal bones involved and determine the extent of osteoarthritis present. Further recommendations can be made at that time. 

    I would not recommend wrapping the knee, as prolonged or inappropriate wrapping can cause pressure sores on the back side of the knee where the accessory carpal bone is located and likely will not provide any benefit in this location.

    I would also use caution in turnout depending on the horse's personality and stabling environment. Hand walking with small paddock turnout until veterinary examination should be considered. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  5. I am looking at purchasing a horse that had medial patellar ligament splitting performed four years ago. Is this something I should be concerned about?

    (View Answer)

    Thank you for your question regarding medial patellar ligament splitting in a potential new horse. As with any prospective new horse, a full pre-purchase examination can not be underestimated.

    This procedure is generally used for upward fixation of the patella otherwise known as 'locking stifle'. The theory is that by splitting the ligament, scar tissue will form as it heals, thereby thickening and shortening the ligament so that it cannot get hung up over the medial trochlear ridge of the femur. This is also used in combination with increasing strength exercise in the hind end with hill work, transitions etc...

    As part of a prepurchase exam, lameness is evaluated both in hand and under saddle. Flexions are performed of each limb and radiographs may be taken. Based on these results, your veterinarian may recommend radiographs and/or ultrasound of the stifle region.

    Your veterinarian can discuss with you their findings and take into account what you would like to do with this horse for a living whether that be as a pleasure horse or upper level performance as to make a recommendation if this horse would be suitable for you. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  6. My horse has medial collateral ligament tears to the coffin in both front hooves. The recommended therapy is stem cell injections and then rest. Now I am conflicted as one veterinarian says use fat derived stem cell while the other says that they get the cells from bone marrow. Should I do this method of treatment, and if so, which one?

    (View Answer)

    Thank you for your question regarding collateral ligament desmitis in the coffin joint. Tendon and ligament damage can be a challenge and frustration. Additionally, there are a number of agents that can be injected into the site of damage including 'stem cells', which can be acquired either from fat harvested on either side of the tail head or bone marrow derived.  

    There are advantages and disadvantages to the harvesting and collection of each. Namely: Fat derived cells are processed and available for injection within 48 hrs of collection vs. bone marrow derived can take 2-4 weeks depending on cell yield and growth rate. The harvest site for fat derived requires a small incision on one side of the tail head to acquire fat. Sometimes this can leave a small cosmetic scar/depression once healed, whereas bone marrow derived cells are acquired through a large gauge needle inserted into the sternum in between the front limbs through a very small skin incision that generally heals on its own with no scar. Both procedures require standing sedation and a local anesthetic block prior to collection. Bone marrow aspirate is slightly more technically challenging vs. fat acquisition. 

    Cost is usually similar to slightly more for bone marrow derived cells depending on laboratory/university used and your veterinarian's fees for collection.

    Your veterinarian can further explain any logistical differences and recommendation may also be made based on facilities and equipment available as well as the temperament of your horse for safety concerns during collection.

    Injection procedures for both techniques is the same. Once the cells are received, your horse will be sedated, regional block performed so they don't feel anything in that area and injection site aseptically prepared prior to injection under ultrasound guidance. A temporary bandage may be placed over the site for transport home with a rest and rehabilitation program outlined.

    In terms of which product works better, the jury is still out. There have not been any direct head to head comparisons for similar lesions in horses evaluating healing over time. There have been both positive and negative studies performed for each, with slightly more positive research coming from bone marrow derived.

    More importantly, in my opinion, is the comfort level of your veterinarian with the harvesting technique, appropriate injection directly into the damaged area of interest under ultrasound guidance and a strict rehabilitation program that is followed with frequent rechecks by your veterinarian. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  7. My veterinarian prescribed exercises (ground pole walking) to encourage adhesion breakdown. Does this often cause some heat in the injured area as it responds?

    (View Answer)

    Rehabilitation for soft tissue injuries can be challenging for both you and your horse. Often times, a gradual increase in exercise is usually prescribed with a combination of increased hand or tack walking, walking over poles or cavaleties and further increasing to include trotting and cantering for a short amount of time with a gradual increase in time, depending on response. This is usually performed on good flat footing, on a straight line, avoiding sharp turns and lunging. Usually, increasing work is done at gradual intervals with a check by your veterinarian before moving up to make sure that your horse is responding appropriately and is cleared with the possibility of being able to handle the increased work.

    Additionally, it is important for you to evaluate the injured area each time before and after you excise your horse. This is in the form of visually looking at it, does it seem more swollen than normal? As well as by physically touching (palpating) the area, to feel for any increased heat or pain related to you touch.

    Without knowing what soft tissue structure or limb your horse is injured on, or when they were injured and what level of rehabilitation exercise you are up to, it is hard for me to give you specific information.

    In general, heat is an indicator of inflammation and inflammation can be caused by over use and may also cause pain. If there are adhesions (scar tissue) in the injured area, increased exercise can cause them to break down. This can also be painful to your horse and the breakdown, can cause inflammation. Walking over poles on the ground encourages your horse to lift it's legs higher up and over the pole vs. walking normally. This causes increased flexion and extension across the joints of the lower limb.

    I would contact your veterinarian to describe to them your findings and they may want to come out to revaluate your horse. Depending on what they find, they may recommend backing off on this increased work for a period of time before moving back up again, especially if there is increased pain, heat, or lameness. Don't be discouraged, sometimes this happens and does often require a fluid back and forth conversation between you and your veterinarian. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  8. How real is the chance injections cause infection?

    (View Answer)

    You ask a very important question regarding joint injections. Current literature suggests that the incidence of infection post joint injection is extremely low as long as the appropriate precautions are taken prior to injection.

    Your veterinarian likely has a very strict protocol for joint injections to do as much as possible to mitigate this risk. This may include: injecting your horse in a clean, quiet environment with the barn doors closed to reduce air turbulence and possible dirt contamination of the injection site. Aseptic preparation of the injection site with a surgical scrub and alcohol wipe down. Use of sterile gloves, needles and syringes with a new bottle of medication and antibiotic used in the joint. Applying a sterile wrap over the site post injection. Reduced exercise and bathing/hosing for a few days post injection and a gradual reintroduction to exercise under saddle.  

    If joint infection were to occur, generally speaking it is most common to see clinical signs of non-weight bearing lameness, heat, pain and swelling associated with the joint within 3-5 days post injection. However, it has been seen as far out at 14 days.

    Joint injections certainly have their place in helping our horse's comfort level when an appropriate and complete lameness examination has been performed and other diagnostics (nerve blocks, radiographs, ultrasound, nuclear scintigraphy, MRI, CT etc.) are used to determine the specific site of pain causing the lameness. Injections should be used when needed, and not prophylactically as 'routine maintenance', as this could be detrimental to the joint cartilage if injected without a need into a normal joint.

    Anytime a needle enters into a synovial space, there is always that slight risk of flare (inflammation without infection) or infection. So the fewer times the synovial space is entered with a needle, the less chance there is of that occurrence. Thank you very much again & good luck! Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  9. My mare was recently kicked on the flat muscle of her shoulder. Two days later, she became swollen down to her ankle. I have given her a tetanus shot and am keeping the wound clean. Is the swelling normal and is there anything else I should be doing?

    (View Answer)

    Thank you for submitting your question. From what you describe, I would strongly encourage you to have your veterinarian out to evaluate your mare. Evaluation and proper cleaning and suturing of the wound site is important to make sure that all dirt, debris and any foreign bodies are removed as well as suturing any skin flaps to allow for appropriate and timely healing of the site. Also, evaluation of the limb to make sure there is no evidence of fracture, muscle tearing or synovial structure involvement is imperative.

    Additionally, with large wounds as you describe, antimicrobial therapy may be necessary. When swelling expands down the limb, that may be indicative of infection under the skin, also known as cellulitis. Without appropriate care, this cellulitis can extend into the blood stream becoming a systemic blood infection and may also cause laminitis, both of which can be life threatening.

    Your mare would also benefit from pain relieving medication, prescribed by your veterinarian, not only to combat the initial traumatic injury, but to help with soft tissue swelling associated with the development of cellulitis.

    A tetanus booster is a good first step, but depending on the vaccination history of your mare, a tetanus antitoxin vaccine may be needed.

    Local therapy to the swollen leg will also help, in the form of cold hosing and wrapping +/- leg sweat or poultice to help draw out any swelling. Your veterinarian should guide you in how to appropriately perform this procedure.

    If you do not have a veterinarian, please search for one on the AAEP website using the following link:  http://www.aaep.org/info/getadvm

    I wish you the best of luck with your mare and finding or calling your veterinarian for evaluation and treatment. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  10. I would like to ask about ringbone. Are there treatment options for ringbone and if so, how do they work? The history is on a 2-year-old horse that the ringbone appeared at 7 months of age. He was always in the paddock and suddenly I saw the ringbone begin.

    (View Answer)

    Your question regarding ring bone in a young horse is a challenging one, without seeing and evaluating your horse or having any additional information.

    Generally speaking, ring bone (arthritis of the coffin joint (low ring bone) or pastern joint (high ring bone) is a chronic progressive osteoarthritic disease in middle to older aged horses. It is usually secondary to chronic repetitive trauma or soft tissue instability of the joint.

    In young horses, ring bone usually develops secondary to trauma to the bone, growth plates or surrounding soft tissue structures that give the joint stability. Additionally, conformational abnormalities, which places abnormal stress and strain across the joint, can also cause progressive arthritis.

    Evaluation by your veterinarian is critical. This would include a physical and lameness examination. Also the extent of bony remodeling across the joint can only be assessed by radiographs, this will also help to identify which type and extent of ring bone your horse has (low or high). The surrounding soft tissue structures should also be evaluated by ultrasound, as they may have originally been damaged requiring a different form of treatment or they may become damaged by impingement of the new bone growth from the ring bone.

    There are various treatments available that should be prescribed by your veterinarian. Systemic anti-inflammatory medication to help alleviate pain related to chronic arthritis is a good first step. Additionally, intra-articular joint injections with corticosteroids can help ease inflammation and pain associated with chronic arthritic pain. There is a topical anti-inflammatory cream that can be applied temporarily as well as shock wave therapy. Lastly, surgical fusion of the joint with plates and screws is also an option, which eventually can provide pain relief by inhibiting motion across the joint space and fusing the two bones together.

    Your veterinarian will be able to best guide you in the decision making process after evaluating your horse. Best of luck with your horse and I would encourage you to contact your veterinarian for further discussion. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  11. I have a 14-year-old Tennessee Walking horse that experienced some kind of traumatic injury in the pasture last summer. He was diagnosed with an injury to his back and stifles. He had multiple injections that helped his back end but then had additional symptoms later diagnosed as an injury to the neck and arthritis in the neck. I was told to get another series of injections but that I could wait to see if there is improvement. He is better but still appears to have some discomfort. The place recommended for injection would cost an additional $1500. Is this the type of injury that would benefit from injections and are ultrasounds needed to be effective or is there cheaper effective options?

    (View Answer)

    Thank you for your question regarding your horse's traumatic pasture injury and associated injection treatments.

    It will be difficult for me to provide you any recommendations without a definitive diagnosis of your horse's specific problem. It sounds like initially there were back and stifle problems and now there are problems with his neck.

    As with any traumatic injury, initial treatment usually includes some period of rest with anti-inflammatory treatment along with progressive increase in exercise/turnout with regular rechecks with your veterinarian. Additionally, other diagnostics may be performed concurrently such as radiographs and/or ultrasound to regions of interest that may be causing pain, lameness or performance issues. Nuclear scintigraphy is also an option to identify bone, joint or soft tissue inflammation when dealing with the possibility of multiple sites.

    Sometimes with trauma, it may take awhile for all injuries to appear and be diagnosed. This is usually because they are delayed in showing (as with arthritic changes, which can occur due to trauma) or because there was some other part of the body that was more injured, thus hiding any additional problems. Once that problem resolves, the other problems are then noticeable.  

    Cervical (neck) arthritis can respond to injection of the cervical facets when performed under ultrasound guidance by an experienced veterinarian. Arthritis is generally determined based on physical exam, palpation of the neck, evaluation of range of motion in combination with radiographs. Arthritis can form on the outside of the cervical vertebral column as well as the inside, which can impinge on the spinal cord causing neurologic signs. This is best diagnosed with a myelogram, under general anesthesia.

    There are a variety of other options to consider including systemic anti-inflammatory agents, shockwave, topical treatments, acupuncture, chiropractic and/or massage therapy, however I would encourage you to speak with you veterinarian about these options, as they may be contraindicated in your particular horse.

    I know it can be frustrating to have to deal with multiple issues and repeat injections. It is also reasonable, as you mentioned, to try tincture of time to see what happens. This is all dependent on you, your horse and performance level or need, keeping in mind that sometimes after trauma, there could be injuries that remain indefinitely regardless of the treatment option chosen. At which point, maintaining the comfort of your horse should be what is most important. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  12. I have a 6-year-old Arabian mare. In October 2015, I noticed swelling above her RH fetlock. I thought it was an abcess and treated it as such. The swelling went down some. She never seemed like she was in pain, or lame, so I continued to work her lightly. My veterinarian came out in December for a lameness exam and ultrasound. Though she was not lame, the ultrasound showed inflammation and fluid under the tendon. We started with shockwave therapy, stall rest and hand walking for one month. After this time, another examine was done in which the swelling had went down further, continue with stall rest and ride at a walk 30 minutes for one month. At the two-month check, swelling was almost completely gone, but now the vet says she thinks she looked better a month ago? She told me small paddock turnout and 30 minutes riding with 5 minutes trot.

    I'm confused as to why she wants me to trot her if she looked better last time? The veterinarian said she seemed a little sore even though you can palpate, flex, etc. with no problems. Is there something else I should be doing? When dealing with inflammation, do the tissues sometimes never return to their previous state?

    (View Answer)

    Thanks for your question, though it sounds to me like you're doing everything correctly! 

    Yes you're right, sometimes when there are lumps/bumps and swellings, they may never go back down to their original size and look like normal again. This is horse and location dependent. As long as there is no evidence of lameness or major tendon fiber disruption on the ultrasound, your veterinarian sounds like they are doing the appropriate graduated increase to exercise program. This usually is a slow transition from stall rest with hand walking, to increased hand walking, to small paddock turn-out, to tack walking, to walk and trotting under saddle and so on and so forth dependent on the owner, horse and facility combined with regular repeat examinations by your veterinarian prior to increasing workload until your horse is back to its previous level of exercise. This is an abbreviated form of physical therapy that most are able to do at home.

    Horses are similar to humans in that if you 'don't use it, you loose it'. Like when you take a month off from the gym and then go try to run or lift weights like you used to, it will be harder and you will get very sore. Sometimes, horses can look worse on rechecks just by virtue of being on reduced exercise. Sometimes they can look worse because the problem truly is getting worse. This is for your veterinarian to figure out. As long as everything else checks out alright with the lameness examination and ultrasound, it is usually OK to slowly increase the level of exercise.  

    I would encourage you to continue to follow your veterinarian's instructions in addition to your regular rechecks. If there is any change for the worse (ex: increased heat, pain, swelling, lameness), please contact your veterinarian immediately.  If there is concern about the level of exercise you are being asked to provide, I would also direct you back to your veterinarian who would be best able to address your questions and make comparisons from one visit to the next. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  13. Are horses with Equine Metabolic Syndrome (EMS) prone to laminitic episodes following joint injection?

    (View Answer)

    Thank you for your question regarding joint injections in the Equine Metabolic Horse (EMS). To date, there have been no definitive published research studies establishing or linking a cause and effect between joint injections in the insulin resistant (IR) or EMS horse and laminitis in the veterinary literature.

    That being said, horses with a previous history of laminitis and those horses who are obese and/or have been diagnosed with IR or EMS , older, debilitated horses with multiple other systemic problems may be at an increased risk for complications secondary to joint injections with corticosteroids. Corticosteroids are potent anti-inflammatory and analgesic (pain relieving) drugs and may affect certain metabolic pathways depending on type of steroid and dose used. This in turn may, in a very small percentage of horses exacerbate in a laminitic flare or bout.

    While joint injections are very helpful to those horses where the lameness has been localized to a certain area and there is concurrent intra-articular arthritis or synovitis (inflammation of the joint capsule), it is not an innocuous procedure and could be detrimental to a normal healthy joint with no indication of inflammation. There as always a risk, albeit low, of joint flare or infection post injection even when all appropriate steps to aseptic preparation and post injection care are instituted. Therefore, joint injections should be carefully considered and risk analysis performed by your veterinarian. Generally speaking, the universal rule of thumb is that the lowest level/dose of corticosteroid should be injected that will elicit a response regardless of horse age, breed, use or history.

    If your horse is considered to be in the possible higher risk categories described above, alternatives to corticosteroids that also provide an anti-inflammatory effect could also be considered if joint injections are considered to be necessary. That could included: platelet rich plasma, IRAP, mesenchymal stem cells, Legend or Adequan. A similar low risk of flare and/or infection is still present with these drugs as well. It is always best to have your veterinarian evaluate your horse for lameness and identify the source of lameness with appropriate diagnostic tests prior to just simply injecting a joint based on a hunch. Your veterinarian will take into consideration the age, breed, use and prior history coming up with a plan for an appropriate injection protocol. They can also go through and explain to you the pros and cons of each option. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  14. Why do some horses experience laminitis after joint injections?

    (View Answer)

    Thank you for your question regarding joint injections. To date, there have been no definitive published research studies establishing a connection or cause and effect between joint injections and laminitis in the veterinary literature.

    That being said, there may be certain horses that veterinarians may be more wary of injecting corticosteroids. Those would include horses with a previous history of laminitis and those horses that are obese and/or have been diagnosed with insulin resistance or Equine Metabolic Syndrome. Corticosteroids are potent anti-inflammatory and analgesic (pain relieving) drugs and may affect certain metabolic pathways depending on type of steroid and dose used.

    While joint injections are very helpful to those horses where the lameness has been localized to a certain area and there is concurrent intra-articular arthritis or synovitis (inflammation of the joint capsule), it is not an innocuous procedure and could be detrimental to a normal healthy joint with no indication of inflammation. There is always a risk, albeit low, of joint flare or infection post injection even when all appropriate steps to aseptic preparation and post injection care are instituted. Therefore, joint injections should be carefully considered and risk analysis performed by your veterinarian. Generally speaking, the universal rule of thumb is that the lowest level/dose of corticosteroid should be injected that will elicit a response regardless of horse age, breed, use or history.

    If your horse is considered to be in the possible higher risk categories described above, alternatives to corticosteroids for joint injections could also be considered if joint injections are considered to be necessary. That could included: platelet rich plasma, IRAP, mesenchymal stem cells, Legend or Adequan. It is always best to have your veterinarian evaluate your horse for lameness and identify the source of lameness with appropriate diagnostic tests prior to just simply injecting a joint based on a hunch. Your veterinarian will take into consideration the age, breed, use and prior history coming up with a plan for an appropriate injection protocol. They can explain to you the pros and cons of each option. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  15. My stallion suffered a traumatic injury that resulted in the front of his cannon bone of his hind left exposed and severed both extensor tendons; rolled and put his leg through an electrobraid fence. It took 8 months for the wound to heal. He was braced for 12 weeks and stalled with only hand grazing for 8 months. He has had no lameness; walks, trots, canters on right lead and gallops with no difficulty. However, his leg is still swollen. It has improved, but I'm having to keep him wrapped at night and in a exercise boot during the day. Anti-infammatories don't help much at all. With the initial injury, all his tissue was resting at the top of his fetlock. My question is: Will the swelling/cellulitis ever improve and is there anything I can do besides wrapping and light exercise to help it resolve?

    (View Answer)

    Sounds like you had quite the ordeal to manage with your horse and that with the appropriate bandaging, splinting and stall rest, he was able to heal completely.

    With an injury as extensive as you describe, it is likely that he will always have swelling in this region. It is also likely that the swelling may wax/wan depending on exercise, turnout and bandaging. The reason this occurs is due to scar tissue that is formed during the healing process. Additionally, with an extensive lower limb wound, not only do the soft tissue structures become traumatized, but the local capillaries, veins, arteries and lymphatics also become disrupted and do not heal back to what they once were. That leaves the horse with a chronically thickened leg from scarring as well as reduced ability to drain lymphatics.

    Generally speaking, once an extensive wound has healed completely and the horse is able to resume turnout and light exercise or riding under saddle, swelling can be managed with as much turnout as possible (with or without lower limb boots) and if stalled, placement of a standing wrap may help to aid in compression.

    As long as there is no residual infection from the wound, the scar tissue will continue to remodel over the course of months to years, however; unfortunately will never go back to it's original state. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  16. I have a horse that kicked a board off the back of his stall and cut his leg. I started taking care of it immediately, but it ended up getting bad. It was frozen and what the veterinarian thinks is proud flesh has been removed multiple times. Unfortunately, it is back again. Any suggestions? It does not bother him, but when riding, he seems to have restricted movement. Could this be from thenscar tissue? If so, is there any way to help with that?

    (View Answer)

    Your question regarding proud flesh is a good one. Thanks for your submission! As I am sure you are aware, horses are prone to injury, especially to their lower limbs. Depending on the location of the initial injury, complete healing can take a long time and may require special care.

    In general, when proud flesh recurs, there are several factors that should be ruled out by your veterinarian. The first and most important is infection or foreign body of the local soft tissue structures or underlying bone from the original injury. The second is stabilization of the joint above and the joint below the wound with either a multiple layer bandage and/or a splint. This is important because with excessive movement, the wounded area can not heal properly, as each time new skin forms, it is disrupted and broken down in a repetitive cycle leading to the production of proud flesh (excessive granulation tissue). The third is that new skin needs to grow over a smooth, flat, non-infected surface. With excessive proud flesh, once it is thick enough to protrude above the non-wounded skin edge, new skin cannot adequately grow over the area.

    I would encourage you to schedule an appointment with your veterinarian to re-evaluate your horse and based on their evaluation, other diagnostics or treatments may be implemented (antimicrobial therapy, radiographs, ultrasound, stabilization of the limb by bandage and/or splint). It is likely that the proud flesh may need to be trimmed again and additionally a skin graft can be considered in that region to speed up the healing process. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  17. At the beginning of December, my gelding was kicked on the outside of the left hock. He became very painfully lame. He was treated and seemed to get better, but swelling returned on the inside and front hock. He was lame when it was filled excessively and has been on limited movement and icing and voltaren for the last 4 weeks. He is currently sound but still some swelling in the inside hock. There is no heat or pain sensitivity. It almost looks like a bog spavin. My question is can the fluid be drained?

    (View Answer)

    Thanks for sending in this question as traumatic kick wounds can be a very common occurrence in the horse.

    From what you describe, it sounds like there is residual inflammation and trauma to the area, as you have noted increased swelling and size of the hock as compared to the other side. Trauma and inflammation to the joint can cause increase joint fluid production. This could be temporary or permanent, dependent on if there is any other damage to the joint, cartilage or surrounding soft tissue stuctures present. Four weeks of stall rest, icing and topical therapy is a good amount of time and continued swelling or joint effusion (increased fluid production) may be an indication that there is something else going on within the joint itself that may require additional treatment.

     While draining the fluid from the largest joint of the hock (the tarsocrural, also known as the tibial tarsal joint) is an option if there are no other abnormalities identified, I would recommend that you have your veterinarian out to perform a complete physical examination and lameness evaluation of your horse to rule out any other problem (bone fragmentation or soft tissue injury). This may include palpating the limb, walking/trotting on a straight line and circle on a lunge line as well as flexion examination of the lower and upper limb to determine if there is any lameness present in that leg. It is likely that additional diagnostics may be required (radiographs and/or ultrasound) to assess if there is any boney or soft tissue injury to that area.  

    Dependent on the findings from your veterinarian, additional treatment may be recommended.

    It is always best to identify or rule out any underlying problems first as outlined above, because until the primary problem is resolved, no matter how many times the fluid is drained out, if the inciting cause is still present, the increased fluid production will continue and any fluid drained will fill right back back up again.

    Best of luck to you and your horse and I hope you get to the bottom of why this may be happening! Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  18. I believe that there is a pro and con for everything. With injections, the pros are obvious but what are the cons with injections without any complications?

    (View Answer)

    Thank you for your question about the pros/cons of joint injections! You are right, there are always two sides to one stone and joint injections can be very valuable in certain circumstances.

    Lameness is the #1 performance limiting factor that we face as owners, riders and veterinarians. Ideally, lameness should be localized by your veterinarian after performing a complete lameness evaluation. Once the lame limb is identified by watching your horse go at the walk and trot on a straight line and circle, along with completion of flexion examination and hoof tester evaluation, diagnostic anaglesia ("Nerve Blocks") should be performed to localize the region that is causing the source of pain that is creating the lameness.

    Once the area of lameness is identified, other diagnostics may be indicated that may include: Radiographs, Ultrasound, MRI and/or CT scan and Nuclear Scintigraphy. Lameness can be caused by a multitude of factors, not limited to: Bone bruising, arthritis, soft tissue injury, trauma causing noninfectious synovitis (inflammation of the lining of the joint capsule, causing increased production of fluid).

    Joint injections can be performed with multiple products depending on the situation, site and need (ex: corticosteroids +/- hyaluronic acid, platelet rich plasma, IRAP, legend, adequan) help to relieve inflammation, provide pain relief as well as help the joint capsule lining start to produce more normal joint fluid to lubricate the joint gliding surface.

    Joint injections should be used to treat a known, diagnosed issue within the joint. They should be performed judiciously and only when needed (ie: not for 'routine maintenance' like an oil change for your car). Inflamed joints respond differently to corticosteroids as compared to normal or non-inflamed joints. When normal joints are injected with corticosteroids, there is a risk of increased cartilage damage within the joint. So while you may think you are doing something to help your horse, long term, you may in fact be speeding up internal damage to the joint and therefore, speeding up the progression of arthritis within the joint.

    Any time a needle is inserted into a joint, after thorough aseptic preparation of the area, there is always a slight (albeit low) risk of possible joint flair (acute onset of lameness that is caused by an inflammatory response) or infection (acute onset of lameness that is caused by infectious process), even with the absolute perfect preparation and post injection site care.

    Bottom line is to always involve your veterinarian in the evaluation and decision making process when it comes to joint injections. After evaluating your horse, they will complete a risk assessment to determine if joint injections my help or hinder your horse. Amy Poulin-Braim, VMD, DACVS-LA, Neshanic Station, NJ

  19. I have a 15-year-old Rocky Mountain gelding that has had two bouts of laminitis and is now stabilized. He has also had a locking stifle. In addition, he has ASD and cataracts. Following the accepted prescription of exercising him on hills and riding on hilly terrain is inappropriate and dangerous for the rider. I want him to be comfortable. He is out 24/7 for three seasons and stalled at night for the winter. My farrier suggested trying joint injections. The horse has cushings and EMS as well. What do you think? I have owned him since he was 4-years-old. He foundered at 6 and again at 12. He is kept in a dry lot.

    (View Answer)

    Thank you for your question related to your horses upward fixation of the patella ('locking stifle').  Sounds like you have a long and complex history for your horse, which can make management tough in some instances.  

    Often times this issue can be multifactorial and a physical and lameness examination by your veterinarian is the best first step. Your veterinarian can determine if the problem is a true upward fixation of the patella, which is a biomechanical problem or lameness due to another region in the stifle that is causing an abnormality in gait due to pain from synovitis or arthritis. There are a variety of other medical and surgical procedures that can also be considered. Every horse responds differently and a combination of options may be required. A visit and examination of your horse by your veterinarian will best be able to tell you what would be the most appropriate form of treatment in your case.

    Generally speaking, the approach to management of upward fixation of the patella begins with strengthening exercises for the hind end. One cause of this issue can be weakness in the quadriceps and/or biceps femoris musculature and/or laxity of the patellar ligaments. You had mentioned hill work under saddle as not being an option considering his eyesight and I would agree with you that this would be inappropriate with a rider. However, this could be done at the walk in hand or if he is otherwise sound and able to be lunged, could be attempted on a low/gradual slope. Also, while working from the ground, taking occasional breaks from walking and backing up several steps (5-10 steps) is another way to help develop the hind end. Unfortunately, this is time consuming and requires consistently, because like humans, 'if you don't use it, you lose it'.

    Conformation is another consideration. If your horse had a very straight 'post' leg appearance in the hindlimbs and/or negative plantar angle of the hind hooves (can be determined by lateral radiographs by your veterinarian), this can also predispose to this issue. While not a whole lot can be done about natural conformation, corrective shoeing can be performed to address a negative plantar angle. This requires a team approach between your veterinarian and your farrier.

    Other additional options would include:

    1) Hormonal therapy (injectable estrogen) anecdotally has been found to be helpful in increasing tension across the patellar ligaments.  

    2) Injection of a counter-irritant ('Blistering') directly into the medial/middle patellar ligaments and quadriceps/biceps femoris musculature. Irritation causes inflammation that leads to scar tissue formation, which shortens or contracts soft tissue, which can help tighten up lax ligaments.

    3) Medial patellar ligament desmotomy is a last case effort when other less invasive medical treatments have failed. This involves transection of the medial patellar ligament such that is becomes impossible for it to become stuck or locked over the medial femoral trochlea. There are other possible risks and complications from this procedure which can be discussed with your veterinarian at the time.

    I would encourage a visit from your veterinarian to help assess your horse's particular needs and they will then be best armed to guide you in the direction that is best suited for your horse with consideration of his medical history, his current housing and what would be in his best interest. Amy Poulin-Braim, VMD, DACVS-LA Neshanic Station, NJ