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Lameness in the Sport Horse by FEI Vet, Dr. Richard Wheeler

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  • Lameness in the Sport Horse by FEI Vet, Dr. Richard Wheeler

    Hi Sport Horse Lovers,

    Just wanted to share an article done by Dr. Richard Wheeler from Palm Beach Equine Clinic. This article was published in Sport Horse International Magazine.

    Lameness in the sport horse

    Dr Richard Wheeler, FEI vet and board member of the Palm Beach Equine Clinic, discusses current and potential diagnostic techniques and treatment options.


    Lameness is described as the result of any structural or functional abnormality of the limbs, neck or back leading to an asymmetry of gait. As we all know, in addition to welfare considerations, lameness in the equine athlete can lead to time out of training and competition and eventually to significant athletic and financial loss.

    The initial approach to the lame horse has generally remained unchanged for hundreds of years. It is here in the observation and examination of the horse that the art of lameness diagnosis is demonstrated. Advances in technology and science have produced several exciting new techniques for the diagnosis of equine orthopedic disease and more are on the horizon.

    Evaluation

    My first step when evaluating lameness is to talk with the trainer and/or owner about the horse's history, current level of training and specific areas of work that may have elicited problems. Subtle lameness may only manifest itself during specific gaits, lateral work or may result in the horse changing its jumping technique. Discussion with an informed trainer can lead us to observe this more rapidly.

    The physical examination begins with a general overview of the horse's condition, conformation and muscle development. I then palpate the neck, back and limbs and examine the feet at rest. Each joint and soft tissue structure is palpated for enlargement, distension, heat and pain and manipulated to assess range of motion.

    The dynamic examination follows. I prefer to observe the horse initially on a lead line at walk and trot and will perform flexion tests localizing the proximal and distal portions of all four limbs. The horse is often then observed on a lunge on hard and soft surface and may be observed under saddle.

    Although I have run through this process quickly here, for me it is a vital part of any evaluation and I will hope to have at least a suspicion of the problems involved by this stage. At the very least we will have identified which limb or limbs are involved and which gaits or situations the lameness is best demonstrated.

    The process to this point is, for me, fairly standard however, how we progress from here is specific to the case. For example, we may have identified an enlarged and painful tendon, or distended joint that is painful on flexion, which would warrant investigation by diagnostic imaging. In the absence of an obvious cause for the lameness however, I will usually progress to diagnostic local analgesia or 'nerve blocks'. This technique is a common but vital tool to the lameness practitioner and involves the infiltration of local analgesic solution around specific nerves in order to selectively desensitize (numb) regions of the limb or specific synovial structures (joints, tendon sheaths and bursae). By numbing these areas we can localize the lameness to a specific area of the limb.

    Once I have identified the area of the body involved, I now want to image the structures implicated. The musculoskeletal system is comprised of bone, cartilage, tendon, ligament, muscle and various connective tissues and synovial structures. The diagnostic imaging techniques utilized will depend on the specific areas of the body involved.

    Radiography

    Radiography involves the use of X-rays to deliver a two dimensional image which today is most commonly displayed digitally in equine sports medicine. Small portable units allow stall-side imaging of much of the distal limbs and larger hospital based units are used for greater image quality and to image larger areas of the body.
    Radiography is especially useful for imaging bone and is therefore used for the diagnosis of fractures, bone cysts, arthritis, bony developmental disease and disease at the junction of bone and soft tissue.
    Recent advances in technology allow us to radiograph more of the body with greater image quality; including the neck and much of the back. Limitations of radiography include imaging of some of the pelvis and deep portions of the back, soft tissues and accurate imaging of complex bony structures.

    Ultrasonography

    Ultrasound waves are emitted and received to provide an image of soft tissue structures and the surface of bone. The use of ultrasound continues to grow and images improve with better equipment and more experienced operators. Ultrasound is the method of choice for imaging soft tissue structures which are superficial and not cased in bone or the foot.
    Ultrasonography and radiography complement each other well and for many years were the mainstay of equine diagnostic imaging.
    Simple ultrasound examinations can clearly see lesions within tendons and ligaments, but will also evaluate more subtle structures such as joint capsules, tendon sheaths and bursae. Although ultrasound waves will not penetrate into bone, they can show us the surface which can be very useful for evaluating subtle changes at joint margins and at the junction of bone and soft tissue structures.
    Veterinarians commonly use ultrasound as guidance for complex needle placement during diagnostic and therapeutic techniques.

    Nuclear scintigraphy

    Nuclear scintigraphy involves an intravenous injection of a radioactive isotope, the radioactivity from which is detected using a gamma camera. Most commonly in sports medicine the isotope binds to or 'labels' areas of active bone remodeling. The image produced shows areas of active bone remodeling as 'hot spots'. Scintigraphy is the technique of choice for the early diagnosis of stress fractures which are common in racehorses and thus it has saved hundreds of lives.
    In the mature sport horse stress fractures are rare but do exist.
    We often use scintigraphy for confirming if a lesion identified on radiographs is 'active' or in complex cases which have not been localized with local analgesia or are difficult to localize by other means. Scintigraphy demonstrates activity as well as anatomy and for this reason it complements the other imaging modalities.

    Magnetic Resonance Imaging (MRI)

    MRI is a complex diagnostic imaging technique which is based on the analysis of the magnetic properties of tissues and can provide images on several planes. Low and high field magnets are available, high field operations offer faster imaging times and higher quality images but currently require general anesthesia. Under general anesthesia imaging of most of the distal limb is possible. Low field systems allow imaging to be performed 'standing' under light sedation. Initially, diagnostic images were only achieved in the foot and pastern regions, however, recently, standing images of the fetlock and upper cannon regions are being reported.

    MRI is sensitive for the identification of bone and soft tissue lesions and images are very detailed allowing detection of subtle changes such as bone edema and sclerosis and subtle soft tissue inflammation. MRI is the modality of choice for imaging the soft tissue structures of the foot and complex areas of the distal limbs. An MRI study provides a huge amount of information and accuracy of interpretation has increased tremendously over the past few years. In my opinion interpretation by a radiologist with experience in sport horses is vital.

    Computed Tomography (CT)

    CT uses technology similar to digital radiography in the production and detection of radiation (x-rays). CT avoids some of the shortcomings of conventional radiography offering a three-dimensional image of exceptional detail. Similar to radiography, CT is primarily used for the evaluation of bony structures and can be of great use in the detection of subtle bone diseases such as subchondral bone injury, stress fractures and bone cysts.
    CT has also been very useful in the assessment of complex fractures prior to surgery. To a lesser extent soft tissues can be evaluated using CT. Techniques involving contrast material have been described and this is a potential future area of development in CT. For the evaluation of soft tissues CT has some advantages over MRI including faster imaging times and the ability to use CT to guide a needle into a lesion in real time for treatment. The limitations of CT include the need for general anesthesia and inability to image larger parts of the equine body.

    Thermography

    Thermography in equine sports medicine provides an image representing the surface temperature of the horse's body. It can be useful in the identification of superficial areas of inflammation and also areas of poor blood flow.

    Arthroscopy

    Endoscopy of synovial structures (such as joints, tendon sheaths and bursae) involves the placement of an arthroscopy camera into a joint, tendon sheath or bursa via a very small 'keyhole' incision. This technique is the modality of choice for the imaging of intra-synovial structures including joint capsule, articular cartilage, menisci and intra-articular tendons and ligaments. The main disadvantage of arthroscopy as a diagnostic procedure is the necessity of general anesthesia, however the potential for direct therapy at the time of surgery often outweighs this.

    Kinematic and kinetic gait analysis

    Gait analysis is used to study the body in motion and aim to provide objective information regarding the animal's movement. Research has shown that computer analysis of single or multiple camera views of horses in motion provided a huge amount of information about the direction and speed of movement of different parts of the body. Various types of force and pressure sensors have also been used, either attached to the ground surface of the horse's shoe or on the ground in a force plate device. However, many limitations were found with these techniques, a lot of time was needed to acquire and process the information and horses move differently on a treadmill than on a working surface.

    Motion and acceleration analysis has produced the most clinically applicable possibility to date. One product available, described as an inertial sensor system, uses three small sensors on the horse's head, right forelimb and croup, which monitor and record movement of the horse at trot. The recorded information is compared against databases of normal horses. The aim is to provide an objective measure of lameness which can be used simply to document lameness but also give objective results regarding improvement following nerve blocks.

    Evaluation of biochemical markers

    Research continues into the evaluation of fluid biomarkers (chemicals found in synovial fluid, serum or urine) that may in the future allow us to detect injury to articular cartilage, subchondral bone, tendons and ligaments in the very early stages of the disease process allowing for early intervention and treatment. Successful development of markers could return huge benefits to athletic horses in terms of injury prevention and guiding rehabilitation.

    Thanks for reading this article. For more information on horse health and sport horses visit www.equineclinic.com.
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