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Sport Horse Lameness: Raising More Questions than Answers

Lameness and medical concerns in the sport horse have increased dramatically and likely are attributed to the increased use and performance level of these animals.  To keep up with medical demands, we have seen an increase in our diagnostic capabilities and technologies as veterinarians.  The concern that I have, as a clinician, is that the drive for these ever increasing technologies to aid in our diagnosis is rising, but it is not being counter driven by new therapies to manage the problems discovered.  We raise our capabilities, hopefully to detect problems earlier, but yet our intervention techniques have not changed, giving the same results in the end for the patient. I think at times, we are missing the obvious when it comes to assisting these patients.

As an equine veterinarian, I recently attended a world renowned convention in which there were many topics on horse healthcare, ranging from medical to lameness concerns.  These conventions are good as they are opportunities to expand our knowledge base.  The problem for me is that in most instances, I leave with more questions than I have answers.

When I graduated from veterinary college, we were still using plain film x-ray technology, which has obviously moved into the digital era.  The image quality is greatly enhanced, allowing us to ‘see’ more than we had before, allowing us to diagnose more conditions due to being able to see more subtle changes that we couldn’t see with plain film technology.  However, with more detail in image quality comes the concern of actually ‘over-interpreting’ the x-rays because we are now also potentially seeing more normal parts of the anatomy that we had never seen before.  Black lines on the film being misinterpreted as potential fractures and darker areas in the bone as cysts, when in fact they are normal findings, in some instances.  One has to understand that there is a huge learning curve to evaluating x-rays or radiographs, thus the need often for a boarded radiologist to interpret the findings to discriminate those small details.  This problem especially complicates the pre-purchase examination as there can be many interpretations of what is good or bad within an x-ray.

Ultrasound technology has been around for a fairly long time and dates back to my college years.  It is a fairly economical method of information gathering, causes no pain, is not invasive and provides a high level of good information.  Again, we have a learning curve with this technology and sometimes we still yearn for more detailed information that even an ultrasound cannot provide.

MRI capabilities soon began to develop for the horse to further our desire for more information.  What was once a form of technology restricted to the Universities, due to cost, it is now in the hands of the private practitioner.  The equipment is very expensive, often exceeding the cost of the average home and thus is used often, to help pay that mortgage.  There is a learning curve in terms of image interpretation and once again, we have the concern that we may be over-reading the images and seeing things that don’t exist or do not create problems for the horse.  Now, with time, those clinicians that use these technologies become more proficient, especially when comparing images with perceived ‘normals’, so we can enhance the ability to determine what is normal and what is not.

Essentially, when we are presented with a lameness, we’d like to localize it and see those tissues in real life so we can understand what is going on.  The only way to actually see those tissues in real time is through surgery, which generally is utilized as a last resort option.  Radiographs help us to see the bony structures and ultrasound allows us to see tendons, ligaments and other soft tissue structures with more detail.  Still, we crave more detail, thinking somehow this will allow us to better manage the condition and give a more precise prognosis, thus we move into MRI and CT technologies.  But, is it better overall?

A Loss of Connection

What I see is that in many instances, we have gradually moved from the art of observation and the skill of using our hands to using technology to get our answers.  Instead of training our minds and eyes and even ears to recognize a lame horse and localize the problem, we are turning to computer programs to localize the location and technology to diagnose the problem.  This leads to detachment from the patient in my opinion.  There has even been increasing discussions of moving the MRI capabilities into the pre-purchase examination, which throws everything out the window.

At the convention I was recently attending, equine clinicians were discussing tendon and ligament injuries that were only being diagnosed by MRI methods, which implies that the damage was so subtle that visual localization and ultrasound were unable to detect the problem.  Essentially saying that we were catching these lesions earlier than before, which is a good thing and it opens the door for many opportunities in terms of therapies from my point of view.  However, despite this, the clinicians still employed the same traditional therapies including rest and pain medications.  Then, upon re-evaluation, some of the horses improved while some were the same or even worse.  In some of those that improved, the horses returned lame again after some time with worsening of the condition, often to find that the problem had intensified and the damage was more severe.  Sometimes, the condition had progressed to the point of mandated retirement for the horse.  Why?

These are great clinicians and peers in my field.  They are able to pinpoint the exact area of injury and able to detect subtle lamenesses that I scratch my head looking at, but in my opinion we need to do more with this new found information.  If we are detecting problems earlier than ever before, then we should act on that information for the benefit of the patient. The question comes as to how?

Now, these fancy modes of diagnostics are being used in early stages of disease, but they are also being used in later stages. As an example, one of the most common situations I encounter on consultations is heel pain in the horse, often ongoing for months if not years.  The problem is evident, exams have been done, even nerve blocks and x-rays, which all point towards navicular degeneration.  We can see it and even hear it in the patient as they walk on a hard surface.  Due to the condition not being responsive to traditional therapies, the patient is then sent for an MRI.  This is where confusion sets in for me, personally.  This MRI exam inevitably indicates more soft tissue damage, usually involving ligaments, joint capsules and tendon structures in an around the navicular region.  This is all well and good, but in reality, is it really news?  Did we not expect this on some level? And even so, now that we know that there is more damage, how does this expensive diagnostic change our course of action?  The reality is that it doesn’t.  Most will say that this new found knowledge doesn’t impact therapy course, but more so changes prognosis.  This is debatable from my point of view.  

In our research and rehabilitation facility, I have always held the view that an expensive test is only warranted if it changes the outcome or my course of therapy.  In the case of most chronic joint and/or tendon injuries in horses, it is to be expected that the damage usually exceeds that which we can see with traditional diagnostics.  More advanced technology can certainly reveal much more, but to me, it doesn’t matter as I expect that and don’t need my client to invest high dollars to make this evident.  I think the technology is cool and interesting to look at, but here again, we have lost our way to an extent.  Many of the horses that we work with are retired due to chronic injury, unable to return to prior level of work.  Most of them have had fancy tests from x-rays to MRI’s, even incorporating more advanced therapies such as stem cells and IRAP, to no avail.  I expect a high degree of damage and honestly, to me, it doesn’t really matter.  It is what it is and the higher level of damage just implies the harder I have to work for that patient.  It doesn’t imply that the prognosis is grim or bleak, but more so just tells me that there is a challenge lying ahead.  If these devices were correct in dictating prognosis for a specific injury, then we wouldn’t have the success rate that we do in our facility. To be honest, in our program, I rarely use even an ultrasound to evaluate patients as they progress.  I am more interested in that patient, how they are doing, how they are feeling, than what I am on what an image tells me.  Radiographs (x-rays) are more commonly used, but not necessarily for joints but more so to monitor foot and hoof health.  Despite this low level of technology approach, we provide over 80% response rate to these chronic patients, often returning them to the prior level of work or beyond.

Research has been done for decades demonstrating the impact of inflammation on tissue degeneration, injury and healing.  This information is not debated, as clinicians know this for a fact and refer to it as a contributing cause of lameness and injury.  We know that certain cellular pathways are activated, contributing to healing but also adding to disease progression and tissue degeneration.

We also know, from research, the role that nutrition plays in health through protein and nutrients.  We know that some herbs impact the inflammatory process in a very positive way without side effects and benefiting health and healing, possibly accelerating tissue repair  and controlling tissue degeneration.  Despite knowing all of this, which is supported by research, clinicians do not incorporate this knowledge into their treatment regimens.  Why? When we have research data to back up potential for use and no known side effects, why would we NOT take advantage of this research for the patient’s benefit? What could be the harm in trying?

Reasons Why Nutrients and Herbs are Not Utilized More Often

  • One commonly encountered excuse is stated as the lack of proven efficacy for various nutrients and herbs in the management of various conditions.  I don’t understand this response.  Sure, we may not have a study using a specific herb or nutrient for say tendon injuries, but we do have one for joint conditions, which demonstrates impact on the same cellular pathways.  For that matter, we use NSAID medications in these patients without proven efficacy in specific conditions, but more so use them because we have extrapolated their use from other instances or disease conditions.  Why don’t we simply ask what is going on at a cellular level in these patients, then ask how we could possibly intervene and what else could we do to support those involved cells and encourage repair?
  • The second most common reason is a general lack of education on behalf of the clinician.  Is it their fault?  Yes and no, simply put.  As clinicians, tending to many patients with a wide range of conditions, it is not feasible to ask them to keep up with all of the research.  After all, we learn from our peers, which is the purpose of the conventions.  If our peers don’t know or don’t use these treatment options, then likely others won’t either.  This lack of exploration transfers from one generation to the next and the problem continues. Just because a person does not ‘believe’ in herbs or nutrition, or the power within, does not make it true. 
  • The third reason I believe these therapy options are not being used is because there is concern over safety and liability on the part of the clinician.  As a veterinarian, we often look to others for therapy options, hoping that they are tried and true.  As doctors, we like to stick with what we know, what we are told, regardless of whether if that therapy is efficacious or not.  One of the biggest things we look for is whether if our peers are utilizing this approach and if it is considered a standard.  By doing this, we don’t go outside of our comfort zones and reduce liability.  We can say that we did everything we could for that patient, meaning we employed standard therapies, but yet maybe the outcome wasn’t great.  The real trick is to think ‘outside of the box’ implementing nutritional approaches to help support the body in the healing and recovery process. 
  • The fourth and final reason is that simply put, many veterinarians believe that pharmaceuticals are the only way to go.  There are many reasons for this, including lack of education, profit motives and heavy marketing by pharmaceutical companies.

I am not implying that nutrients and herbs are the end solution to every problem, but they do provide a needed level of support and fill gaps in our current therapies.  If we can have patients respond to nutrient and herbal therapies that have been through all other routine treatments without improvement and destined for retirement, then just imagine the possibilities if we engage those early stage cases.  MRI and other advanced technologies are great, but let’s use them as a tool for early intervention, not just as a prognostic tool.  The body can only function through a steady supply of proper nutrients.  We have to understand that many of these horses have increased demands for nutrients and have a higher level of activation of many negative cellular pathways.  If we can see this, then we can understand that there is an opportunity that we can intervene and change the course of events.  Is it possible to reduce the incidence of lameness in the horse?  Is it possible to slow joint degeneration despite the high level of use and stress?  Is it possible considering the high demands that we place on them to enhance recovery and performance?  In my opinion, as a veterinarian, the answer to all of those questions is “yes”, but we will never know unless we start to implement other therapy options.  We have to realize that there are limitations to everything, which includes pharmaceutical options.  Sometimes, I believe, we get too complicated in our initial approach to a problem, when in reality, a more simplified one will yield better results.

Personally, I think that there are tremendous possibilities and opportunities to help these athletes.  Looking at Curcumin and Boswellia research data, we see that possibilities exist to use this combination of herbs to help control ongoing inflammation which is not only contributing to many injuries (tendon or joint), but also impacting the healing process.  We also have to take into consideration that many of these horses are undergoing oxidative stress as a result of exercise, training and competition.  The excess level of free radicals is also impacting cellular health, contributing to injury and joint degeneration.  This is a process which could be impacted by adequate levels of antioxidant supplementation including vitamin C, vitamin E, CoQ10 and alpha lipoic acid.  The other consideration is protein and amino acid supplementation, which can not only impact tissue repair but directly impact cellular function and recovery from a variety of conditions. The key here, though, is not just seeing the potential, but applying these options at the correct doses and combinations for that patient.  

The research data is there, but now we just have to apply it in our therapies, helping these patients to succeed.  We have proven the value of supplementation with these vital nutrients and an enhanced level of nutrition on recovery in our patients, cutting rehab time and enhancing overall results.   As a horse owner, rider or trainer, you do have options to help enhance your horse’s health, performance and recovery.  Implementing nutritional changes and herbs for their medicinal activity can create dramatic positive changes. The answers are there, but now we just need to implement them on a broader level and take charge.

Some imply that I look too deeply, attempting to ‘fix’ things that just can’t be fixed.  I don’t accept that, as a doctor.  After all, as a doctor that is what we are supposed to be doing for the benefit of our patients, never giving up and constantly seeking all options…right?

 

All my best,

Tom Schell, D.V.M.
Nouvelle Research, Inc.

www.nouvelleresearch.com

 

 

 

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