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October 3, 2013

Between Rounds: Context Is Key In Sports Medicine

Advances in diagnostic technology, such as MRIs, have revolutionized equine sports medicine. But the information they provide has to be balanced with judgement and experience. Dusty Perin photo.

As diagnostic and therapeutic technologies expand, it’s ever more important to see the big picture.

There has been an explosion of new information in the equine sports medicine field, with new or expanded imaging technolo­gies available and more commonly in use in the performance horse industry. In addition, there are new therapies available for treatment of injuries and performance-induced wear-and-tear.

After spending time in our clinic observing MRIs, nuclear scintigraphy and regenerative medicine treatments, a student asked me if the new technology-based diagnostics and sub-specialization of equine sports medicine will change the profession, with the technology reducing or limiting the diagnostic role of the practitioner. The question seemed both timely and relevant.

Ever More Information

Technology such as MRI and nuclear scintigraphy and improvements in digital radiography and ultrasonog­raphy allow veterinarians to identify anatomy and pathology that once could only be seen during a post-mortem examination of the horse.

Healthy and unhealthy anatomical structures that were not even paid atten­tion to in the past can now be identified. For example, veterinarians are much more in tune with the fact that neck and back problems can cause major issues in horses even if the horse appears sound, because technology has enabled specific, accurate diagnosis and targeted treat­ment before lameness appears.

Similarly, the current therapeutic options we now have for treatment of an injury are far greater than anyone would have imagined 20 years ago. Shockwave therapy, laser therapy, visco-supplementation, TILDREN and regenerative therapies such as stem cells, bone marrow, IRAP, platelet-rich plasma and combinations thereof are readily available.

In fact, now there are so many alter­natives that it can become confusing and unclear as to which therapy is right for a given horse. In thinking about some of my immediate and challenging cases, there are many where technology alone does not provide a straightforward diagnosis.

For example, stiffness in a client’s horse was caused by a large splinter in its mouth, and a difficult-to-diagnose lameness was caused by a blood clot.

In both cases, technology helped see the problem but could not explain the relationship.

There are other cases where veteri­narians disagree about how to interpret radiographs during a pre-purchase consultation or an ultrasound during a soundness examination. In another second-opinion case, there were conflicting opinions about how to inter­pret a bone scan, and in yet another case involving many more veterinarians, there is disagreement among experts on how to interpret an MRI.

How can there be such discrepancies if we’ve come so far? And where does the horse owner go to get good advice regarding these issues?

It’s An Art

A strong parallel exists when deciding which therapeutic option is optimal for an injured horse. Reaching out to a number of esteemed veterinary colleagues around the world, I asked them which therapies they feel are most effective. It was not surprising to hear the varied but expert opinions. There was no consensus or single answer. Clearly, there is room for art in the science of equine sports medicine.

What each individual veterinarian does have is his own experience: experi­ence with successes, experience with failures, and a sense of the risk taken compared to the benefit of a given treat­ment. Experience helps a veterinarian decide if an injury needs any treat­ment at all, if the horse will tolerate the needed rest time, or if the client can afford the recommended treatment.

The art of medicine combines the veterinarian’s knowledge, experience and intuition to best help the patient. The effective veterinarian knows the client, communicates well and knows the patient.

For example, a central issue in managing upper-level sport horses is injection of joints and regions with hyaluronic acid and steroids. Just as in human sports medicine, joint injections in horses are done routinely and can have a profoundly favorable effect. Joint injections frequently make the horse comfortable and thereby prevent a horse from sustaining a secondary injury.

However, joint injections can be over­done, masking an underlying injury and compromising joint health. The veteri­narian uses judgment and experience to determine what to treat, when to treat, and how to treat.

When done appropriately, there’s no doubt that therapeutic joint injec­tions can prolong the horse’s career and improve his comfort. At other times, however, there may not be a sports medicine diagnosis to be made. The experienced veterinarian evaluates alternative causes, such as the horse may be sick, overworked, or perhaps it was over-faced and lost confidence.

Like people, sometimes a horse may just need a break or a different partner or a different job! Even if there is arthritis present, that may not be the primary issue. Needless to say, there is not unanimous agreement among veterinarians, trainers and owners as to when joints should be injected or if another solution should be pursued.

With all the information available, and with contradictory opinions iden­tified, clients are often confused and have difficulty deciding among treat­ment options. One veterinarian might say, “Do this,” while another might say, “This other treatment is more effective,” and research and the Internet make everything more complicated.

The client needs good help negoti­ating his way through all the diagnostic and therapeutic information to get a successful end result with his horse.

The Big Picture

Medicine is not an exact science; it is an applied science. Medicine requires understanding the information provided by technology, but it also requires the application of intuition, experience and judgment.

The goal is to leverage the information in a way that gets the best end result. It’s rewarding to the client to have a trusted veterinary practitioner work with him to provide an understandable, correct diagnosis and a realistic, effective treat­ment regimen for his horse. There’s nothing more rewarding than seeing a patient successfully competing because a few good medical decisions were made and treatments were applied.

Science and technology will grow and improve, giving veterinarians informa­tion to better practice and apply the art of medicine. That art requires, however, what it always has: trust, experience, and communication between client and the practitioner to create the best outcome for the individual patient.

Mark Revenaugh, DVM

Mark Revenaugh, DVM, focuses on the diagnosis and treat­ment of lameness and performance issues out of his Northwest Equine Performance practice in Mulino, Ore. Revenaugh evented before attending the University of Illinois College of Veterinary Medicine and first served as a U.S. Equestrian Team veterinarian in 1997. He now serves on the USEF Eventing Team Veterinary Panel.

If you enjoyed this article and would like to read more like it, consider subscribing. "Context Is Key In Sports Medicine" ran in the Sept. 9, 2013 issue.

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