Mystery lameness. Bone scan?

[AlterWhiner]

I’ve been dealing with a mystery hind end lameness on my veteran show horse for about 6 weeks now, and I’d really appreciate some advice about what to do next. He’s been thoroughly poked and prodded by several good lameness vets who can’t diagnose his injury, and he has not improved with six weeks of stall rest.

I’m considering a nuclear scan, on the advice of one of the vets who did a lameness workup, but I don’t really have any experience with the technology. It would be pretty expensive for me to do, and my insurance will only cover a portion of the cost. And my sense from talking with the other vets is that it’s only really good for diagnosing bony injuries, and could potentially miss a soft tissue injury.

So I could use some advice and maybe just some moral support at this point.

Here’s a little bit of history:

He came up extremely lame in his LH after jumping about six weeks ago. Like 4/5 lame--it was not pretty. My vet came out the next day and said he suspected a hock injury--perhaps a collateral ligament strain--given the degree of lameness and some heat in the hock joint. He referred me to the big horsey hospital here for a complete workup.

He went to the hospital a week later and was improved to about a 2/5 after a week of stall rest with minimal daily handwalking. But he did not significantly improve with low six-point, suspensory, hock, peroneal/tibial or stifle blocks, and he didn’t respond to palpation of his leg or back. An ultrasound of his proximal suspensory looked normal. And digital radiographs of his hock showed no fractures or other obvious culprits--in fact, they said his hocks looked surprisingly good for a jumping horse of his age. The hospital vets told me to consider the nuclear scan to try to diagnose an injury higher than his stifle. They felt pretty confident that they had ruled out everything they could.

After two more weeks with no improvement, my original vet recommended injecting his hock and stifle with HA and steroid, since he said there was a decent chance of some kind of joint trauma, despite the negative blocks. I said ok.

About 10 days later, the horse did seem sounder and just before the six-week mark, we tried one day with 5 minutes of trotting to see how he did. The next day, he was extremely lame again, perhaps not as bad as the day of the injury, but significantly worse than the day of his lameness workup.

Any suggestions? Do you think it’s worthwhile to start from the beginning with the blocks, etc. and a different vet? Is the bone scan the right next step? I wish we could at least figure out a general location for the injury. Does anyone have any experience with a high hind end lameness like this?

[Simkie]

If you don't want to jump right into a bone scan, I'd recommend ultrasounding the SI region and radiographing the spine from poll to tail.

Personally, I think your cost to send the horse for a bone scan is going to be nearly the same as doing the above work, and a scan will tell you more. This is exactly the sort of situation where a full body scan is useful. It will tell you exactly where to look next.

Your experiences with your horse are not unlike what I went through with my mare last summer. Her story is here (http://www.chronicleforums.com/Forum/showthread.php?t=161628).

[ImJumpin]

A scan won't diagnose, but it will give you a better idea of areas to look at further. You've done the shot in the dark methods, so at this point you either keep doing those till you find it or you do the scan and pinpoint problem areas quicker. Personally, I'd fork over the money to do the scan-- yeah, the next "cheaper" thing you try might be the answer, or you could try 6 more different things before finding the answer and that is going to add up.

[bit-o-honey]

I'm sorry you are having this problem with your horse, it is so frustrating to try to diagnose with no obvious signs of what actually hurts!

I had a bone scan done on a horse after he stumbled and fell at the canter two times in one week (in the same general area in the indoor arena).

We were not able to diagnose a cause of the stumbling and attributed it to incorrect shoeing and a bad spot in the arena footing. However, the scan did reveal a couple of things we would have never known - a tiny fracture in his "thigh" bone, and a very small area of no bone in his short pastern (like a spot in the bone that was hollow). The fracture was most likely a result of the falls (he was not lame on that leg). The hollow area in the pastern bone was "always" there. Sorry I can't recall the technical terms.

The scan can be misleading because some areas that show up "hot" might be normal and not a source of pain for the horse. In my opinion, it just gave me more to worry about and no real answers.

Have you pulled his shoes and blocked the foot, or looked for abcesses/corns, etc? Whenever I see a horse that lame with no heat or swelling in the joints or obvious places, I think feet or major supporting joint (like hip or shoulder). The feet are fairly easy to investigate, whereas the scan might be helpful for the stifle/hip/sacroiliac areas.

Good luck with it and have patience, time off for him can help the healing process.

[Lieslot]

The scan can be misleading because some areas that show up "hot" might be normal and not a source of pain for the horse. In my opinion, it just gave me more to worry about and no real answers.

I can agree with that. A few years back my WB kept on having back issues, bucking under the saddle, upset about the leg, saddle slipping as he was moving crooked etc. Anyway long story short, had his spine X-rayed and vet said, oh some dorsal processes are coming up very close, ie kissing spines. We did a bone scan to be sure and guess what... absolutely no hot spot in that area whatsoever, so vet said forget about kissing spines he's fine.
Well a year later still troubled with the same issues, different vet clinic, X-rays again telling the same close DP's, another scintigraphy and again no hotspot over back. I gave up there.

But honestly now 3 years later he can still have times where he's very difficult under the saddle wanting to buck etc, and I'm left to wonder if he might just have kissing spines .... But I will not repeat the bone scan, coz probably it'll tell me nothing again.


On another note. Same horse was 3 legged lame in front and vets blocked way up & way down and couldn't figure it out. Bone scan revealed collateral in the hoof as well as radius ulna of the same leg, hence blocking up or down never got him sound. So in this case it was a great diagnostic tool.

[AlterWhiner]

If you don't want to jump right into a bone scan, I'd recommend ultrasounding the SI region and radiographing the spine from poll to tail.

Personally, I think your cost to send the horse for a bone scan is going to be nearly the same as doing the above work, and a scan will tell you more. This is exactly the sort of situation where a full body scan is useful. It will tell you exactly where to look next.

Your experiences with your horse are not unlike what I went through with my mare last summer. Her story is here (http://www.chronicleforums.com/Forum/showthread.php?t=161628).

Ugh. I hope it's not cervical spine. Vets are only recommending a scan of the back end. I can only imagine how pricey the whole horse must be.

One possibly reassuring difference (if I'm reading your posts correctly) is that my horse has had no longstanding lameness or pain issues and that the lameness was quite quick in onset and severe at first--which I think points to an injury and not a more chronic issue like neck arthritis. But it would be foolish to rule anything out at this point.


Have you pulled his shoes and blocked the foot, or looked for abcesses/corns, etc? Whenever I see a horse that lame with no heat or swelling in the joints or obvious places, I think feet or major supporting joint (like hip or shoulder). The feet are fairly easy to investigate, whereas the scan might be helpful for the stifle/hip/sacroiliac areas.

I've been hoping abscess all along, but my vet tells me that the low 6 point block would cover the foot. And the horse is not the slightest bit responsive to hoof testers. We have not pulled the shoe, though.

Have you had any experience with acute hip/stifle/SI injuries? I know a few horses with stifle and SI problems, but they all have presented as more subtle, NQR lameness, so I can't go by their experiences for guidance.


Good luck with it and have patience, time off for him can help the healing process.

Thanks! I actually think I'll be a lot less stressed once I know what's wrong. This is my forever horse and I'm fine with doing whatever he needs in terms of stall rest, surgery or PT--and I have a good option of a pasture and some buddies if he needs an extended outdoor vacation. It's just hard trapping the horse in a tiny box for so many weeks and feeling like he's not really benefiting.

[Simkie]

Ugh. I hope it's not cervical spine. Vets are only recommending a scan of the back end. I can only imagine how pricey the whole horse must be.

One possibly reassuring difference (if I'm reading your posts correctly) is that my horse has had no longstanding lameness or pain issues and that the lameness was quite quick in onset and severe at first--which I think points to an injury and not a more chronic issue like neck arthritis. But it would be foolish to rule anything out at this point.


Blush was quite sound until she suddenly was not sound. Initially presented as hock pain, flexed off at the hocks and a hock block switched the lameness to the opposite hind. Totally typical presentation of hocks. Radiographs were inconclusive. She was unchanged 3 weeks following hock injections, which is when the "fun" started :sigh: :no:

If you're going to do a bone scan, just do the whole horse. It's generally $1200 ish. Unless you're in CO, and then CSU bleeds you dry. Mine was $2200. (if you ARE in CO, good luck getting a good scan of the pelvis, though. CSU does not use enough nuclear material to adequately image a large horse's pelvis.)

I really wouldn't be quick to rule out a cervical spine problem, just based on what you've posted here. I suspect c spine issues are not uncommon and under diagnosed.

[AlterWhiner]

If you're going to do a bone scan, just do the whole horse. It's generally $1200 ish. Unless you're in CO, and then CSU bleeds you dry. Mine was $2200.

$1,200 sounds nice. There are two hospitals in my area that do the scans. One quoted me $1,200-1,500 for the hind end. The other quoted $1,700-1,900 for one hind limb, pelvis and back. I can find out about the full body scans.

For reasons that I don't quite understand, my insurance will only pay 50% of diagnostic tests and only covers tests that produce a diagnosis. So I'm hopeful that the scan will be half paid for, but I'm sort of operating on the assumption that I'll have to foot the whole bill, just in case. On the upside, they will cover 100% of treatments.

[Sebastian]

Bone scans are helpful with Mystery Lameness... At least you can get a better idea of WHERE the inflammation is occurring.

But, as others have said, it won't actually give you a diagnosis. I had a mare with an inexplicably sore foot, and it wasn't until we did an MRI that we discovered a strained collateral ligament. But, with treatment, she came back completely. So, it was really good that we got the correct diagnosis. Just "rest" would not have been enough.

Personally, I always feel better KNOWING what it is I'm dealing with...so IMHO, if you can afford it, go for it.

Good Luck!!
Seb :)

[Peggy]

In my horse's case and with a friend's horse the nuclear scintigraphy pinpointed the area. Friend's horse they really didn't have any idea so they did the full-body scan ($1200) which narrowed down an area that was then radiographed and ultimately injected. Horse now sound. Star got the front end from the knees down and both stifles ($800, which makes me think the difference b/w a partial and a full scan isn't proportional to the area scanned). There the soft tissue scan was ultimately more helpful than the bone part. Which led to an MRI ($1700) and ultimately a diagnosis.

I know of other cases where nuclear scintigraphy didn't prove useful. In both of the above cases the vet (different vets) who performed and analyzed the scans also observed the horse clinically. With Star it wasn't his regular vet, but that vet and the one who did the scans apparently spent a long time talking the night after the scans were done. In other words (and many words) IMHO, the more of the picture the vet sees, the likelier it is to get a diagnosis.

[J.D.]

I’ve been dealing with a mystery hind end lameness on my veteran show horse for about 6 weeks now, and I’d really appreciate some advice about what to do next. He’s been thoroughly poked and prodded by several good lameness vets who can’t diagnose his injury, and he has not improved with six weeks of stall rest.

I’m considering a nuclear scan, on the advice of one of the vets who did a lameness workup, but I don’t really have any experience with the technology. It would be pretty expensive for me to do, and my insurance will only cover a portion of the cost. And my sense from talking with the other vets is that it’s only really good for diagnosing bony injuries, and could potentially miss a soft tissue injury.

So I could use some advice and maybe just some moral support at this point.

Here’s a little bit of history:

He came up extremely lame in his LH after jumping about six weeks ago. Like 4/5 lame--it was not pretty. My vet came out the next day and said he suspected a hock injury--perhaps a collateral ligament strain--given the degree of lameness and some heat in the hock joint. He referred me to the big horsey hospital here for a complete workup.

He went to the hospital a week later and was improved to about a 2/5 after a week of stall rest with minimal daily handwalking. But he did not significantly improve with low six-point, suspensory, hock, peroneal/tibial or stifle blocks, and he didn’t respond to palpation of his leg or back. An ultrasound of his proximal suspensory looked normal. And digital radiographs of his hock showed no fractures or other obvious culprits--in fact, they said his hocks looked surprisingly good for a jumping horse of his age. The hospital vets told me to consider the nuclear scan to try to diagnose an injury higher than his stifle. They felt pretty confident that they had ruled out everything they could.

After two more weeks with no improvement, my original vet recommended injecting his hock and stifle with HA and steroid, since he said there was a decent chance of some kind of joint trauma, despite the negative blocks. I said ok.

About 10 days later, the horse did seem sounder and just before the six-week mark, we tried one day with 5 minutes of trotting to see how he did. The next day, he was extremely lame again, perhaps not as bad as the day of the injury, but significantly worse than the day of his lameness workup.

Any suggestions? Do you think it’s worthwhile to start from the beginning with the blocks, etc. and a different vet? Is the bone scan the right next step? I wish we could at least figure out a general location for the injury. Does anyone have any experience with a high hind end lameness like this?

FEET! Lateral palmar wing fracture. usually not recognisiable for 4-8 weeks if medial horn is flared. Flare is relative.

[Watermark Farm]

I'm your "too cheap to pay for a bone scan" cautionary tale.

My horse was 4/5 lame behind, too. A bone scan was strongly recommended. I scoffed at the price (no insurance), then proceeded to spend 3 months and the price of a bone scan with multiple lameness evals, chiropractic, etc.

Long story short, my horse had a fractured pelvis, ultimately diagnosed by an ultrasound specialist (another diagnostic tool for fractures and soft tissue, and relatively cheap). But I'm sorry that I didn't just do the scan. In my horse's case, it would have saved us a lot of time, money, and frustration.

[yellowbritches]

Do the scan. They might not diagnose, but they get you in the area. You will spend a small fortune if you radiograph and ultrasound everything. If you do the scan, it will show problem areas and give you a road map of where to look. Including feet.

[bit-o-honey]

[QUOTE=AlterWhiner;3974367]
Have you had any experience with acute hip/stifle/SI injuries? I know a few horses with stifle and SI problems, but they all have presented as more subtle, NQR lameness, so I can't go by their experiences for guidance.
QUOTE]

AW - Thankfully I have not had experience with acute hip/stifle/SI injuries. If the vet suspects this area, I would go over with him/her what are the best diagnostic tools for bone, joint, muscle, nerve, cartilage, ligament and/or tendon injury. I may have left out something important. A scintigraphy scan will show "heat" or inflammation but I'm not sure if it is in the bones/joints only. What tools can be used to cover the other possibly injured components? I'd get a list of the diagnostic tools for each potential area of injury and discuss with the vet the best plan of attack for investigation. Some of these things can become wild goose chases and it's better to start out fully informed.

Xrays of the foot would not be terribly expensive and would help eliminate or confirm the bone possibilities in this area at least.

Let us know how it goes.

[Simkie]

A scintigraphy scan will show "heat" or inflammation but I'm not sure if it is in the bones/joints only. What tools can be used to cover the other possibly injured components?

There is a soft tissue phase when doing a bone scan. Soft tissue injuries WILL light up, but you have to be looking for them, as the soft tissue phase is brief.

[purplnurpl]

OK, this may sound REALLY stupid but...

Has anyone thought maybe he's got a pulled groin muscle? Something simple like that?
Just a shot in the dark.

And trust me, it could get much much worse than a bone scan. I've dished out 8K over the past 10 months. A bone scan is minor on the pocket book.

[findeight]

If he blocks negative from the stifle down? The pain would seem not to be from the stifle down and that would probably rule out feet. And he is very recent, suddenly and quite dramatically lame with no problems before so that does sound like trauma.

I vote an entire back end scan. Spend the money finding a cause (or where to specifically look for one) not chasing symptoms.

With improved diagnostics, see alot more found to have pelvic, hip and spine issues we never could chase down before.
Good luck.

Oh...and most of the decent clinics that can do the work up for you have several vets on staff plus the ability to consult so, IMO, you don't need a competely new set of tests and another vet for a second opinion. The clinic can send out the results to a specialist for a consult at your request-costs but not like a completely new work up would.

[AlterWhiner]

Thanks everyone. This has been really helpful. I'm going to go ahead and schedule the scan. The vet at the clinic does his own preliminary lameness exam, so if something he sees suggests preliminary foot diagnostics or cervical spine and a full body scan, then I'll defer to his wisdom.

I will report back in about a week.

[findeight]

The vet at the clinic does his own preliminary lameness exam, so if something he sees suggests preliminary foot diagnostics or cervical spine and a full body scan, then I'll defer to his wisdom.



There you go...give the vet the time and opportunity to do the job and then LISTEN to them.

Again good luck and will look for an update.

[Simkie]

Good luck! I hope it all goes well, and that you're able to find the root cause and that it's an easy fix.

Not sure how your luck is, but if I were to do a partial scan on a mystery lameness, I KNOW I would hear those dreaded words: "well, we're really not seeing much..." That's why I would NEVER do a partial scan. I don't think they have to use any more nuclear material or keep the horse longer for full body vs partial (I think it's just more time in front of the machine), but if you have crappy luck like me, I would really push for a full scan, even if the vet doesn't feel it's absolutely necessary.

FWIW, my fabulous vet didn't think c spine until after she went to a conference that was about spinal injuries in equines. After that, she got VERY curious about Blush's neck. I really got the impression that even considering the c spine is still pretty novel at this point...

[AlterWhiner]

OK, this may sound REALLY stupid but...

Has anyone thought maybe he's got a pulled groin muscle? Something simple like that?
Just a shot in the dark.


I was actually hoping for something like this! One of the options the vets mentioned for an injury that wouldn't block was some sort of deep muscle strain that wasn't sensitive to palpation because it was way in there. But, my vets think that six weeks would take care of any muscle strain mild enough to not produce external signs of inflammation.

[sid]

I just went through something like this with my best mare. And I did go forward with the bone scan (of course it does soft tissue as well), looking for a problem in the tibia, hip or wherever.

Stress fracture of her femur was diagnosed, by bone scan only. They could only get one radiograph, once the bone scan showed the focal point of the injury. Typically, they have to go under a general to get all four views, but would not do that for fear of a catastrophic break upon arising from a general.

BUT, by diagnosing by bone scan alone, they cannot rule out bone cancer either. That being said, she's been stalled since the injury and is making improvement (will be stalled for 4 months). So right now, we feel the diagnosis is correct.

I felt I needed to find out, because IF it was any sort of stress fracture, I wanted to avoid a possible catastrophic break -- which CAN happen. I didn't want to "guess".

Good luck.

[purplnurpl]

I was actually hoping for something like this! One of the options the vets mentioned for an injury that wouldn't block was some sort of deep muscle strain that wasn't sensitive to palpation because it was way in there. But, my vets think that six weeks would take care of any muscle strain mild enough to not produce external signs of inflammation.

Nope. My friends Prelim eventer has been out for 6 months with a jacked groin. There was no swelling.

Also, just a thought for the future. Great American covers 100% of bone scans and MRIs.
I was floored when Broadstone only covered 1/2 of my friend's bone scan. Check around and see what others do. Halmark and I think there is one other company that COTHers like.

[Simkie]

Also, just a thought for the future. Great American covers 100% of bone scans and MRIs.
I was floored when Broadstone only covered 1/2 of my friend's bone scan. Check around and see what others do. Halmark and I think there is one other company that COTHers like.

True about Great American UNLESS what they find is excluded as "pre-existing."

This is something I faced last summer with Blush. After her claims for a bone chip removal the previous year, I had a rider on ALL arthritic conditions. When the bone scan popped the neck and the hock, and a subsequent set of rads showed bony change in the neck, they only paid for HALF of the bone scan--the "half" that found the hock (hock rads were beautiful, no signs of arthritis.)

[AlterWhiner]

My horse got the scan yesterday. The vet recommended doing the hind end and back and also suggested getting shots of the horse's front feet, just to have.

It looks like the injury may be in the hock after all. He said they saw "moderate focal uptake" in the point of his hock. He said that could be a fracture or may be related to soft tissue that attaches there. (I'm not the greatest on hock anatomy--but I think maybe the achilles tendon??)

Waiting to hear the results from some new hock rads. They're going to shoot some different views from the last time to get a better look at that bone and maybe do an ultrasound of the surrounding soft tissue if the rads look clean.

I'm still somewhat nervous that I don't have my answer, but I'm suspending judgment for the moment. The vet said that the scan didn't show very good quality images above the stifle because of the size of the horse. And nothing lit up more strongly than "moderate."

We'll see . . .

[Simkie]

I'd consider a hot hock a "good" result. Hocks are generally quite treatable with favorable outcomes.

Did you do a full body scan?

[AlterWhiner]

I have more information, but still lots of questions.

So the bone scan and subsequent radiographs suggest the lameness is caused by an inch-long "osteitis" lesion in the front of my horse's calcaneus bone. The vet said that lesion could be the result of trauma and will heal on its own; could be the result of a tendon avulsion; or could be the site of a sequestrum (Am I spelling that right?).

The vet was not very specific about healing times/prognosis for these possibilities and said there's no good way to distinguish between them without MRI. He did say that a sequestrum would require surgery and that the other two options could be helped by SWT.

Does anyone have any experience with this type of injury? Any guidance would be super-helpful right now.

I do plan to bring copies of the nuclear scan and the radiographs to my excellent lameness vet--who doesn't yet have his own scan. I am hoping he will help fill in some of the gaps. But any advice/stories/links to articles at this point would be very welcome!

[AlterWhiner]

Did you do a full body scan?

No, the vet did not recommend the full body scan. We did the hind end and back. The vet described his certainty that the hock lesion was the cause of the lameness as 95%.

[Sebastian]

Are you planning on doing the MRI? I was amazed by what can be seen on those...

Seb :)

[readytorodeo]

Before I did surgery I would try OCD Pellets. PM me if you want info.:)

[AlterWhiner]

Does anyone know how to edit the thread title? Thought I might get more people familiar with this injury if I posted it up front.

[Penthilisea]

Just another chime in for "do the scan". After months of NQR with my TB, thinking everything from hocks to weak stifles to long toes etc, he has a stress fracture of the ilium. Too deep to ultrasound, too minor to palpate.
And now after 6 months of pasture rest he is coming sound and looks terrific!
Plus the bone scan showed a previous fracture to his left ribcage, which means his bending issues on that side are related to discomfort, not poor behavior. Good to know.