Good afternoon and welcome to the webinar vet. Today's topic will be lameness in sports horses, or just horses, for the new graduate and general practitioner. This is aimed not for specific, lameness clinicians, but for someone with a bit of a, an interest in horses and a bit of an interest in getting into some lameness.
And hopefully we'll have some helpful hints and tips. So our objectives today are to go through defining lameness, having a look at the clinical exam, as well as some of the ancillary tests that go around that, flexion tests, etc. We'll touch on some of the advanced imaging as well as a brief chat about the equinosis Q with the lameness locator, and then get into a little bit of advice for practise.
So what really is lameness? There are many different conditions of it. Some people call it asymmetry, some people call it pain, or any alteration in the horse's gait.
In some instances, it's even just a reduction in performance. The official Definition comes down to something more like lameness is an indication of a structural or functional disorder in one or more limbs that is manifested during progression or in a standing position. And all that means is basically, it reduces the horse's performance.
There are many manifestations of lameness. And they can be called supporting leg lameness, swinging leg lamenesses, mixed lamenesses. You get compensatory lamenesses as well.
And then physical restrictions leading to mechanical lamenesses. Now, not all horses are as lame as the one over there, which is very, very obvious. And most of what we're dealing with are far more subtle than that.
Getting onto grading of the lameness, there is the American Association of Equi Practitioners scale, which is very well defined. They're on a 0 to 5, varying from a 0 being a pretty sound horse to a 5, being a non-weight bearing horse. The issue with this scale is that it's quite limited in that most horses end up being a 2 or a 3.
So by the time you're getting on to doing diagnostic analgesia or trying to discuss subtleties and lameness, it's not very well. Correlated. There is also the 1 to 10 system, which is used in the UK and in parts of Europe.
The issue with that system is that it is not quite as well defined as the American system, where there are very specific parameters. So it tends to become quite subjective. My 2 or 3 will be very different to someone else's 2 or 3.
So whichever system you're using, my advice is to be consistent and to keep using your own system and try not to compare it to other people's systems. So the lameness exam, the purpose of this is really to discuss the systematic steps that are useful in the evaluation of a horse, . And to try and give you a framework with which to use when evaluating a horse.
Now we always start with history and that's one of the most important parts of any exam. Then we go through the process of evaluation, so that's physically having a look at the horse, physically laying hands on them, and then as well as that, a dynamic, assessment as well. This may include manipulation tests, so wedge tests, flexion tests, that sort of thing.
And then going on to part of the evaluation being nerve blocking, which I find very useful. And then some advanced imaging, and that may be both anatomical versus physiological, and we'll touch on a little bit of that later. So what's, what's in a history, and I think this is a difficult thing for many people starting out in that the colloquial terms used by horse owners are varied geographically, varied between people, and some have a completely different language they speak.
So, it's very important to pay attention to what the owner is saying and try and tease out their actual concern. Things like how long it's been lame, do they know what caused the lameness? Was there a traumatic incident?
Is this just a sort of generalised poor performance that's been coming on for a while? And then teasing things out like stumbling or tripping, which may lead you down the course of doing a neurological exam or things like that. These are all very, very important parts of the history.
From my point of view, I think it's very important to ask open-ended questions at the start, let the owner talk freely and let them describe what their concern is. And listen to them. We all have a pre-defined idea many times of what we think we're going to find.
That's called called idiolepsis, wearing blinkers and not being open to a diagnosis, even if it's staring right in front of you. So, although there are breed and sport variations in lameness, and many cases often follow a very similar pattern, it's very important to listen to the owners and pick up on what their concern and what their expectation of your exam is. Cause ultimately, this is what you need to address in a lameness exam.
Yes, we are there for the good of the horse, and we are there to find out what is wrong with the horse. But unless you address the owner's concerns, you're not going to be very, a very good clinician and you're not gonna be very well received. So I think that was one of the, my biggest take home messages is you need to show them what is wrong and explain to them why you've gotten there, and that needs to fit in with their ultimate concerns.
So getting on to the visual exam, a mentor of mine said you'll miss more by not looking than by not knowing. And I do all my lameness exams in a very, very systematic way. They're all done exactly the same way.
I'm fortunate in that I'm hospital based so I can do everything on the same surfaces, in the same environment with the same handlers, and that makes my examination technique very fixed. It does mean I pick up on a lot of subtleties, which I'm very fortunate. To be able to do, but in first opinion case and starting out case, that may not be the way.
So setting up a process where you evaluate every horse systematically, I think is very, very important. Trying to keep to that as much as possible, also lets you pick up on many subtleties and differences because you can compare to what your last couple of cases were. Some of the things not to miss obviously are things like effusions and swellings, posture, muscular symmetry or wasting, and then getting onto the dynamic exam and seeing them on as many surfaces as possible.
So when asymmetry is very obvious, it's very obvious, when it's not so obvious or more subtle like the horses on the left, that's where you might need to spend a bit more time having a look. Now, typically, a full limb lameness, is described as a head nod lameness. This might be quite subtle and more kind of like a shoulder hike.
There may just be a slightly louder sound on the opposite limb versus a full clip clop. And it's very important when looking at these to use all of your senses, so sight and sound, and get a sense of what the, the horse is, is doing. This is most easily seen, usually with a horse coming towards you.
There's a little diagram. So when the lame leg is up, the head is lowered, and when the lame leg is down, the head is raised. So try when you're starting out, fix your eye on one point, whether that's a point on the head or the tip of the ears, or the pole, and try and use that point, the same, or the same point in every exam, that you get a bit of a feeling of looking at the same thing.
Hind limb lameness is typically described as a hip hike. This is caused by the shifting of the of the pelvis to accommodate the movement through the the painful limb. The lame side tends to be the one that moves through a greater range of motion.
This has been proved with many lay studies, as well as observational studies and intra-observer studies. Different people focus on different places. I tend to focus on the tuba coxa.
Some people focus on the point of the hock. One good tip when you're starting out with this is, if you're unsure, put tape tags onto the tubercoxer onto the sacrum. You can even do them onto the point of the hocks.
And that allows you to see these very well. It also often helps to demonstrate to an owner that a hip hike is occurring because you have a bigger excursion through one side of the pelvis versus the other. Hind limb lameness is the best seen of a horse going away from you.
And this we've seen in, in one of the videos coming. It is still important to have a look at them on many surfaces and to try to see them from the side as well. When you're looking from the side, what you're really looking for is arc of flight, between the feet, so looking for toe dragging or anything like that.
Does the horse pick the leg up, engage, and step in underneath? And are the strides symmetrically and equidistant? So here we have a forum lameness.
This, as you can see, it's obvious enough that you can see it going away. There's a very obvious head nod. You'll see it better on the way back.
. And you can see as that right foot hits the ground, the head does tend to come up. One of the important things when trotting horses is to have a handler who knows what they're doing, is consistent and doesn't put tension on the lead rein as that may upset a subtle head nod. So here's a hind limb lameness now, when he gets going.
This again is quite obvious. You can see that left hip moving through a very large range of motion versus the right. And then you can even see a little bit of a tentative step around the corner.
And as he comes back, as you look over the hip, you can see that large range of motion through the pelvis again. Mhm Palpation is an essential part of every lameness exam. Again, try and be systematic, try and get through everything.
You're not always going to be able to elicit pain responses, some stoic type horses, native breeds, cobs. What you may not, what you may get instead of a pain reaction is a boarded or protected reaction. So specifically through the back, they may not want to flex their hock or pick up their leg in response to the fact that they anticipate some pain, .
But it's very important to palpate every joint, feel for heat and feel for symmetry as well. Moving on to some more manipulation tests, hoof test is should always be performed, it should be performed in every, lameness exam. They should be applied across the whole foot, so the sole, the frog, the heels, .
The various, theories as to how they should be applied to, illicit pain and navicular syndrome, or across the soul. But again, a systematic application is very important. As you can see there, in the diagram on the right, essentially you're doing is applying pressure to the hard part, the capsule of the soul, and that's then placing pressure onto the structures, the sensitive structures of the lamina and the bone underneath.
By the theory is by applying it across the heel, or across the sulcus of the frog and the As a hoof wall on the side there, you can create a greater surface area for which to apply the pressure. Important adjunct to lameness exams, are manipulation tests. These can be passiflexion tests or range of motion tests.
So checking that a horse can bend its neck to the left and to the right, can get it down to the bottom, has a full range of motion through all of its limbs and joints. Many of these are very important things. What you will be able to feel often is, as we said, more of a guarding motion rather than a full pain reaction.
And then there is the full or distal limb flexion with a static hold and the limb held up, fixed prior to a horse trotting off. Now, again, there's dispute as to what constitutes the correct time. I don't think there is a correct time.
I think what is more important is that you should always use the same time. So whether you do it for 30 seconds, 45 seconds, or 60 seconds, do that repeatedly in all of your exams. Wedge tests are, basically where you put a plank of wood with a wedge or a triangle elevation underneath the foot.
Now these can be put on the sides or to elevate the toe. Generally, a wedge test is used to exacerbatepodotrochlear pain, or if you have a suspicion of navicular pathology. So here are some demonstrations of range of motion tests.
So getting the horse to have a treat and bend its neck round to the side should be able to bend the whole way round and touch its hip, as well as the belly, should be able to curl its neck down and touch the floor between the legs. And then you can see Doctor Gillon there is extending the forummb of a horse through a full range of motion in the central picture. My general approach to lameness evaluation, and this was taught to me and taught to many students is again to be systematic and try not to jump to where you think, start again, as I said, systematically.
Is the horse sound or is it lame? Do you think it's in front or behind, or both? Do you think it's left or right or both?
And then give it a grade. Do this every single time you see a horse trotting, whether it's on the straight, whether it's on the lunge, and where possible, try to record this. It's gonna be very, very important for your notes.
But also when you start getting into doing regional anaesthesia or nerve blocks that you know where you started and you remember where you started. Every time you look at a horse, try and look at it as if it's the first time, whether it's pre-block or post block, assess it with as fresh a pair of eyes as you can without any biases where possible. And by using this system where you go, is it sound?
Is it lame? Is it in front? Is it behind?
Is it left? Is it right? Is it both?
And then giving it a grade will set you in good stead, and you can then compare apples to apples, essentially by comparing one thing to another. And you'll know whether your blocks are working and you hopefully will not get any unconscious biases. So you want to use your baseline examination, which is assess the horse under all of its gates.
So walk and trot, and canter where possible. This should be done in both straight lines as well as on the lunge and where possible on multiple surfaces. So if you have access to an arena, do that in an arena.
If you have access to a concrete drive or a firm packed soil drive, do it on that as well or a lane, . The other very important part about a full baseline assessment is to reverse the horse. So back it up.
You're gonna pick up things like shivers or some neurological dysfunction which you may not see otherwise. Also very important where possible to see the horse on the saddle. This is where many of the manifestations of lameness are noted, and specifically subtle lamenesses will often be exacerbated with a rider on top.
It will also give you an idea of how the horse responds behaviorally to the lameness. There's some studies about pain face and lameness and that sort of thing. This is, it's a bit beyond the scope of of this talk, but if you're interested in that, there are some things to read further.
Gait variations. So trotters and pacers, again, try not to panic when faced with these, try and be as systematic as possible. Most saddle breds tend to have hind limb lameness, but this can refer through to the for limb.
And I think again, getting good history of where these horses have their problems is a good place to start and then just being systematic and working through it. So, as we said, your baseline, you want to see the horse going away from you and back towards you. But it's also important sometimes to see them from the side.
And here you can see the symmetry of the legs as it's moving. And then it also means you can measure how they track up, so the length of their stride, which is very important to assess. Seeing them on the lunge as well.
Again, be sure that you see them both ways, similar sort of time. So if you're gonna do 30 or 40 seconds on one rein, try and do 30 or 40 seconds on the other. I try and do the trot both ways so that I have that as a direct comparison, then do the canter both ways after that, that it's not affected by one time or the other.
Again, that's my personal preference and how I do it, but, whatever system you have and works for you, stick to it. Flexion tests, as we said. So basically what that is, is putting the limb into flexion.
What this does is compresses one half of the joints and extends the other part of the joint joint, so it puts pressure on the capsule, and that extension can put pressure onto the cartilage or onto extends tendons over the joint and compresses the capsule on the, other side of the joint. Now, two ways to do this just by doing the distal limb and then doing the proximal limb independently. My feeling on this is often that, as you can see, once you flex a limb, you're, you're putting some load through all of the joints.
I tend to not do, distinguish between lower limb flexions and upper limb flexions. I think it's a fairly, non-specific test anyway, so I tend to do full limb flexions. Moving then to regional anaesthesia, local and intra-articular blocks are very, very important part of the lameness exam.
Their accuracy varies. Obviously, particularly for perineural blocks. We're trying to get as close to the nerve as possible without poking it.
This can vary on injection technique as well as the status of the tissues, and the local that is used. Generally, the thought of a 50 to 60% improvement is significant. For most cases, you'd want at least an 80% improvement.
So, depending on your grading scale, if you've got a 3 out of 10 lameness and you're blocking it to a 1 out of 10, that gives you a 66% improvement. You've changed two grades, that's probably fairly significant. Whereas if you, only have a, a half a grade change or a 1 grade change, that might be slightly more subtle and you might want to continue doing some blocking.
Again, very important to check the timing of your blocks. If you're leaving them too long, you may end up with migration of the agent, and this may lead to some false positives. There's recently been a very good study showing that, blocking of the stifle and leaving it for longer than 15 to 20 minutes, means that you may block out some foot lamenesses in the hind leg.
So, again, sometimes these are more art than science, but they are very definitely a valuable adjunct to the lameness exam and should be performed where possible. It's something also to become experienced and comfortable with, and to know your limitations of. But certainly, when you get good at them, they are invaluable.
So getting into the analgesia a little bit, I'll cover sort of the, the distal limb blocks in this talk. First off, generally in sequential order is a Palmer digital nerve block. Now, this is specifically gonna block conditions of the foot.
So it's done there on the, Palmer aspect of the foot, as you You can see over there on the lateral aspect or lateral and medial aspect of the deep digital flex tendons, and kind of between the collateral cartilages of the foot. Needles generally, stuck downwards, and local is infiltrated there. What this will block or potential conditions that this may affect onpototrochlear apparatus problems.
That includes heel pain syndromes, wing fractures of P3, sub-solar abscessation, and in some cases, pedal osteitis. So, as we said, your abactxial border of each sorry, moving on to the abactial sesamoid nerve block. This is one step higher up, and what this does is the phalanx or the phalanges, the coffin and past and joints, pretty much the entire hoof capsule as well as the sole, parts of the dorsal branches of the suspensory ligament, parts of the extensor tendon, your distal sesamoid and ligaments, and may do parts of the sesamoid bones as well as the fat lock joints.
So it's very important to remember that your abaxial sesamoid, you may be blocking part of the fat lock joint. This is the position for the nerve block over there at the base of the sesamoid, and both done both medially and laterally. Moving up then to the low 4, this is performed at the base of the splint bone for the one part, and then between the tendons, proximal to the tendon sheath for the other part, again, done both medially and laterally.
So this will block out all structures previously noted, as well as the soft tissue structures of the fetlock, as well as part of the branches of the suspendory apparatus and the digital tendon sheath. And the needle there on the left for the low 4 point. In the hind limb, you can do a low 6 point where a third needle is placed onto the dorsal aspect next to the extensor tendon in theory to get some of the dorsal branches.
In this In case, you may not in the 4 point, you may not lose sensitivity to the dorsal aspect of the skin. But there are probably some good studies as well to show that this may not be needed and that a low 4 point and a hind leg may be sufficient. Moving on then, once you have found out your source of pain, is the next thing to decide is what you're going to do about it and how you're gonna come to diagnosis.
This is generally where imaging comes in. And there are two types of imaging as far as I'm concerned, anatomic and physiological imaging. So anatomic describes things like radiography, ultrasound, CT.
MRI is debatable as to whether it's a pure anatomic or whether it's physiological. Physiological imaging would be more things like nuclear centigraphy, PET scans, or thermography, where you're physically where you're assessing the physiological activity of structure rather than what is just there. And then further diagnostics, if you're not coming to a good answer with those, would be magnetic resonance imaging, CTs, neurological exams, and some other specific tests where and when needed.
So getting on a little bit now to the in the so-called lameness locators, there are a number of commercial systems available. The most widely used is the Equinosis Q, was previously called the lameness locator. It's now equinnosis Q with lameless locator.
The lamus locator is essentially the software. What this is is a number of small body mounted, inertial sensors. They have, gyroscopes and accelerome.
In them. And what they do is they physically measure the horse in space, or points on the horse in space, as well as pitch and roll and up and down. So, the sensor on the head will, is very, very sensitive for head nod.
The sensor on the pelvis is very, very sensitive for roll. So pitch and roll. And essentially what that's doing is measuring hip hike.
The one on the head essentially is measuring head nod. And then there's one on the front leg, which basically is set to measure the phase of stride. So what that does when it's all put together into an algorithm, which is fed wirelessly through to a tablet, that then calculates where exactly the horse's head is in time, compares left to right, as well as the pelvis left to right.
And this can then be done on the straight, as well as on the lunge. This is very, very useful because it takes a large set of data. Your eye can only analyse a certain amount of asymmetry, every couple of seconds.
Whereas this is a magnitude of sort of almost 200 times what your eye can measure. Again, it's this is completely objective. There's no subjectivity in in it, but the subjectivity comes in in the interpretation of the results.
So if you're using these systems, it's very important to understand how they work, the flaws in them or they, What their limitations are. You still need to have a look at the horse, you still need to observe the horse, you still need to do a full lameness exam. These are just very, very useful adjuncts to that exam.
Where they're particularly useful is in nerve blocking, so having a baseline lameness and then being able to objectively quantify your change in grade pre and post block, as well as in teasing out some of the subtle multi limb lamenesses. One of the very interesting things that's come out of the inertial sensors is, and particularly this system is what is called the law of sides. So previously we used to think that or the common thought was that lameness always compensated across a diagonal.
So if you had a right front lameness, you might get a left hindlimb lameness and vice versa. What this has seemed to show after much, much work and many horses, is that a primary hind limb lameness tends to compensate epsilaterally to the same side on the front. And a primary front limb lameness can compensate contralaterally to the hind.
So that's what's called the, the law of sides, and it's quite an interesting thing to have noted since the use of these sorts of systems. There are other body mounted systems as well. Some are commercially available, some are not, but I think this is an area that, again, it's good to get into and I think will become very useful in the future.
So here is the system in action. As you can see, there is a tablet over there. These are the inertial sensors.
One is head mounted, one is foot mounted, and one is pelvis mounted. It then gives you a nice printout of the asymmetry and the timing. And if you know what you're looking at, you can then work out which is the primary part of the lameness, which is the secondary part of the lameness.
It divides the lameness up into an impact phase versus a a push off phase. And front and back, left and right as well. If you want to, it has a little algorithm which basically interprets things for you and gives you a summary.
But I would advise, which is very useful to start, but I would advise if you are using a system like this to try not to use that, look at the system itself, look at the horse and come up to your own conclusions. Right, we'll get on to one or two case studies now. First case is a 12 year old Irish sport horse mare used for low-level eventing and some general riding.
The owner reports that she's been struggling to canter and saddle and up hills, has started to disunite the canter. Owner turned her out for two weeks in a paddock. She was initially better.
But is now back to a previous level. The owner thinks that she is deteriorating. Unfortunately, the video for this, would not link, so we're just going to have, you're gonna have to take my word for it.
On exam, she was boarded through her on palpation through her back, . Mildly 1/10 lame, both hind legs, depending on which circle she was on, on the lunge. Fairly symmetrical on the straight, but didn't seem to lack an arc of foot flight, and positive to flexion of both full limbs behind, no change in front.
Diagnostic plan in this case was put to the owner, that we could do sequential nerve blocks, or other thing to do would suggested was because there was multi-limb lameness of both hind legs, as well as a suspicion of some back pathology, we discussed some advanced imaging, and in this case, what we just spoke about was nucleus integraphy, which is fortunate what the owner went for. And these are some of the stographic images. Now, essentially, what nucleus integraphy is for those who are uninitiated is a radioactive isotope which is attached to a bisphosphonate that is used wherever there is bone metabolism.
So same as children and londrenate, wherever there's bone turnover, that protein is used. We attach the radionucleotide to the, the protein, inject it venously, make sure the horse has got good circulation. And it's nice and warm.
That then circulates a couple of hours later, we take a gamma camera and get some images of the horse. So wherever there's abnormal physiology in the bone, that protein will accumulate, and that then comes up with increased radiopharmaceutical uptake or what we call hotspots. So you can see it gives us a nice definition of the skeleton here.
This is obviously the hock. You can see the long bone there, point of the hock, small tarsal bones over there, and then going into the cannon. Left is left, right is right.
And you can see there's a large accumulation of protein on both left and right, right over the distal and tarsal joints. It's asymmetric on the DP views there as well. This is now in the thorax of the horse, and you can see over here.
So this is scapula over there, horses facing to the right, Dorsal spinous processes of the wither, going to the thoracic spine, ribs down over there. This is the continuation of it over there, focused slightly more. This is a shot from the left, going down.
Into the lumbar region. Same thing on the right below. The increased uptake over here is the kidney, and the same thing over there is the kidney over there.
And that's because the pharmaceutical is excreted by the kidney and the urine. You can see over here, there is increased uptake in the dorsal spinus process regions. And once we had completed the scan, we chatted to the owner and suggested some radiographs.
These are the radiographs of the horse. So over here we have the horse's head again pointing towards the left. These are the dorsal spinous processes through the thoracic region, and you can see there's a number of overriding dorsal spinous processes.
Now the nucleus inigraphy is very, very useful specifically for . Overriding spinous process of kissing spines. And the reason for that is that if we took X-rays as a survey of many horses, we will find these bony changes.
These are very often associated with no clinical signs, and that's why it's important to, if you are going to take X-rays to have. A coup, a bit more of a discussion with the owner that you may find these things, they may be incidental, but it also needs some work to determine their, their relevance. So in this case, we had Positive, clinical signs.
So we had back pain both on palpation as well as written behavioural issues. We have radiographic change in that we have overriding spinous processes there, and you can see there's sclerosis on them. There's modelling, there's some lucency in some of them as well, some early cyst formation.
The whole summits have changed shape, so we know that there is, there is definitely bony pathology there, and we can correlate that to Our bone scan, where there's increased radiopharmaceutical uptake. So we know that that is physiologically active. It's painful, which means we can then confidently say this horse has back pain, that pain is probably related to the kissing spines, and then we can give them some options for treatment.
Further radiographs also showed marked osteoarthritis of the distal intoarsal joints. So you can see left again is on the left there and right is on the right. These are lateral to lateral projections of the left and right tarsus.
And you can see there is almost complete obliteration of the distal arsal joint there with marked per-articular osteophyte formation. Same thing over here, and some bridge and callus almost over the top of it over there. So our diagnosis in this case was distalinarsal osteoarthritis, as well as overriding dorsal spinous processes, or kissing spine.
What we did in this case was to do some intra-articular analgesia of those DIT joints which improved the horse's way of going. Got rid of that sort of 10/10, 1/10 hind limb lameness. We got the owner in to ride it.
It did, however, not improve its way of going in the saddle when we then blocked the back, so we did an infiltration of local anaesthesia in and around those overriding dorsal spinus processes, the horse's way of going improved greatly. Treatment options for this, then, again, that's slightly beyond the scope of this talk. But in this case, the owner wants to start with some conservative management, so it had some steroid injections into the back and into the hock, as well as a rehabilitation programme.
And the horse went back to doing. What it was intended to do. There are also obviously surgical options for this.
So should the conservative management no longer work, we can then chat about cranial wedge ostectomies or total ostectomies of the dorsal processes, as well as facilitated ankylosis of that distal interarsal joint. Second case here is an 8 year old Palomino used for Western riding. 3 weeks previously went acutely lame when he came in from the paddock, was seen by a colleague from the practise for a Hind and lamus was given phenylbutasone.
She was taken off and the foot was poulticed on that limb. There was no improvement after 7 days. The shoe was put back on by the farrier, partial improvement was noted.
The horse was then arrested for 2 weeks. When it came back into work, went lame again, was then presented to you for further examination. So the plan in this case was to do some, or as discussed with the owner, we started with a full physical exam.
There was no obvious heat pain or swelling, a marked hind limb lameness, and we went with, OK, let's start with some diagnostic analgesia, as well as then move on to some imaging pending what we find there. So the blocking pattern here was PD negative, abaxial negative, low 4 or low low 6 in this case was a hind leg, but we still did low 4. That was negative.
And then we went with, well, where do we go to from here? Radiographs taken of the Tarsus, survey radiographs were essentially unremarkable, as was discussed with the owner. And so what we then did was do some ultrasonography.
And here we have the . Ultrasound. So this is a longitudinal view over there, as well as a transverse view over here.
And superficial is on top, deep is over there. Check ligament over there, and then suspensory ligament underneath. Now, on this suspensory ligament, you can see there are some changes.
There are changes to the back of the cannon bone over there. There's a little bit of an osteophyte on it over there. And then there are changes through the anatomy over there.
There's a lack of fibre pattern. It's bulging on the dorsal surface and some irregularity on it over there. Once we had these imaging findings, we then went and did a deep branch and the horse went sound on blocking to the deep branch.
More of the same images over there. Treatment options were discussed with the owner. In this case, again, surgery with the fasciotomy neurectomy was discussed, as well as conservative management with, a rehab programme.
So restricted exercise in conjunction with shock wave therapy, That is what the owner elected to do was to start a graduated exercise or some rest, followed by a graduated exercise programme, as well as 3 rounds of shock wave therapy. Horse responded very, very well to that and went back to doing its Western riding. In time, we'll see how that gets on.
It may end up needing surgery, but certainly responded quite well in the first instance to conservative management. So, those are just two fairly common and fairly classic types of cases. Just to kind of go through a little bit of the decision making process.
Now, they don't always follow the, follow the rule book, but I think as we said in the beginning, if you have a good idea of what you want to do and you follow the plan to the letter, at least you then have somewhere to go and you've got a bit of a structure to your exam, and the owner knows what to expect from the exam. So as we said, the purpose of this really is to narrow your suspicion to a region. And then once you've got a region to then go in in depth and have a look with either imaging, Or other further diagnostic tests, and then to come up with an appropriate therapy.
All of that lets you essentially give the owner a bit of an idea of what their expected outcome is, how long they think this is going to take, and what sort of, owners love a percentage. So being able to say, well, you know, the literature says 80% of these come back to doing. What they were doing before.
If you're confident of your diagnosis, you can pull that out and say, look, that's where we are. Or by the same token, say, you know, these are really, really terrible injuries, and actually, there's only 30% of them come back. You can manage owner expectations, and looping back to the beginning part of the discussion, that really is what the lameness exam is all about, is managing owner expectations and giving them a good answer.
You're never going to give them a good prognosis all of the time, but at least if you can give them a good answer and manage their expectations, you've come 80% of the way. Inertial sensors, I think are becoming more and more prevalent throughout lameness exams. I think they definitely have a place.
My concern with them which I think is voiced by some clinicians is that if you do not have experience in performing lameness exams, they can end up becoming a little bit of a crutch or become a little bit of a a hindrance in your developing of your skills. So my suggestion would be if you are in a practise that has an inertial sensor, that is a great thing and I think you should use it, but it is. As an X-ray or as an ultrasound, it is a tool to help you make a diagnosis.
It's not there for the sole purpose of, of the diagnosis. It's part of the exam, it's not the whole exam. And that would be my, my top tip for using those is to do your exam, use those as an adjunct and see how you get on with them, and see if you can correlate their findings to your findings, and see how the two of them mesh together.
So in conclusion, I think, essentially hack lamenesses are no real difference to sport horse lamenesses. In some cases, they may be more subtle. It's very important to listen to the riders or to the owners, and to manage what their expectations of lameness is or what they want to do with the horse.
Very often we want to go in and do all sorts of expensive tests or, radiographs and do nerve blocks and get stuck in. In some cases, the owners are not expecting that. They're not wanting that.
And we need to explain to them why that needs to be performed or not performed in in certain cases if you can come up with something straight away. For example, if you, you see a horse with a bigger fused digital tendon sheath, it's very, very positive on palpation of that, it's positive deflection of it. You can turn around.
Go, well, we're not going to do systematic blocks of that. What we may just do is block that 0 she that's very obviously diffused, do that as a first off, and then you can have your answer. Same thing for joint effusions or things like that.
If you have a horse that has a very, very, obviously diffused joint. That may be a starting point. By the same token, don't be confused by or fooled by a horse that has effusions.
Try and be systematic and try and be and rule everything else out before you go targeting on just one thing. So make sure that your examination is critical, that you . Keep trying to prove your objective.
Don't, as I said, don't, get blinded by idiolepsis and get stuck into one specific diagnosis because it fits the box. Try and disprove that as much as possible. And when that's the only thing that is left, then you know that you have the right, diagnosis.
And whichever way you perform your exam, be systematic and be thorough and perform the exam the same way every single time. That's ultimately what's going to lead to your success in lameness diagnostics. Right.
So that really is pretty much my top tip is be systematic, palpate as many horses as you can so that you know what normal feels like. Very often you'll pick up very subtle things through the tips of your fingers that you didn't see, and never be afraid to palpate a horse to palpate a horse every time it's in the clinic, every time you're doing a vaccine, every time you're out doing something. Feel what a horse's back is like, feel what a horse's neck is like, test their range of motion a little bit, feel their joints, feel their tendons and their ligaments, get to know them, specifically when you're starting out.
And even later on, that you know what normal is. And as I said, that then means that very subtle things will come to you, as you, as you're doing your exam, particularly because you're systematic and you go through everything. Again, I cannot stress this enough, is treat your owner expectations, listen to owners and listen to what their concerns are, and don't just focus in on what you think their concerns should be.
. Top tip for everything in in veterinary science is we, we think we are there treating animals, but really, we are treating owners. And communication is key. So, listen to them, listen to their problems.
It takes 5 minutes, and very often we're stressed and in a hurry, and we don't feel like we have those 5 minutes, but that may make your life sufficiently, better in the long run by listening to what the owner's concerns are and addressing those. Feel, look, look again, feel again. Never be afraid to repeat your exam.
If you can't see it, trot it up and down a number of times on a number of surfaces until you can be sure that you do see it. If you have a lameness that you feel is blockable, by all means go ahead and do some regional anaesthesia. But if you don't feel like you've got a Constant enough lameness or a lameness that is significant enough to block, don't go ahead doing nerve blocks because you can't block what you can't see.
And ultimately, trust yourself, because you've gone through the training, you know what you're doing, back yourself a little bit and be, realistic about what your limitations are. So you don't want to be going into these things with no experience at all, but you need to do them in order to get some experience. So back yourself a bit and do as much as you can, and don't be afraid to ask for advice or to refer where and when needed.
Couple of references over there. And then what we'll do is move on to some questions. We've got 5 multiple choice questions here.
I will basically read them through so you can read them on the screen there. Pick one, and then we'll give you about 30 seconds to pick one before we come up with the answer. So first one, nice and easy.
See, what is the definition of lameness, asymmetrical movement of the limbs, causing dysfunction and to the forward motion of the horse. Lameness is an indication of a structural or functional disorder in one or more limbs that is manifested during progression or in a standing position. Lameness is a non-painful mechanical restriction causing asymmetrical movement in the gait pattern, or lameness is pain in a single limb at any point in the anatomy, causing a limping or hopping type gait.
So obviously the answer there is #2. Moving on to the second one. Which of the following is unlikely to be affected by a Palmer digital nerve block, the podotrochal apparatus pain as number 1, P3 fractures as number 2, osteoarthritis of the proximal interphalangeal joint as number 3, or sub-solar abscessation.
Most unlikely one there is osteoarthritis or the proximal interphalangeal joint. So, past and joint arthritis is unlikely to be blocked out by a palm digital nerve block. What would be a good indication or a good candidate to be referred for nucleus integraphy.
A horse with a multi-limb lameness. A horse that has clinical indication of back pain with or without suspected sacroiliac involvement, a horse with a suspected stress fracture, or all of the above. In this case, it would be all of the above.
What is the law of sides? Lameness always compensates on the diagonal leg. Lameness in the front will always compensate to the epsilateral side.
Lameness in a hind leg never causes compensatory lameness on the same side, or none of these. And the answer there is none of these. When might a wedge test be performed to determine the amount of heel elevation needed on a shoe in a case with suspected navicular disease, 3rd for carpal osteoarthritis, or 4 in a case suspected to have overriding dorsal spinous process impingement.
And in this case, it is cases with suspected navicular disease. Very good. Thank you for your time and I hope you found that useful.
As I said, be systematic, back yourself, and get out there and help some ponies.
