Stocking up or lymphedema is a familiar term to many horse owners and often is used to refer to a horse that exhibits leg swelling. Cellulitis is another term that is often utilized in the horse with chronically swollen legs. The exact cause of the swollen leg can be variable and with this, so can the prescribed treatment course. The more we understand, often the better we can assist these patients, but it is a complicated problem in the equine industry. The good news is that with the right therapy approach, the outcome can be greatly enhanced.
One of the most common scenarios amongst horse owners is to have a horse that stocks up or swells up in one or more legs, especially after stall rest or even one night of confinement. Terms including lymphedema, lymphangitis, and cellulitis are commonly used, having similar clinical findings but different origins. We have many remedies for these situations, but often the problem persists despite, coming and going with moderate variability. In order to understand , we must lymphedema or stocking up in the horse we must have a deeper look at anatomy and physiology.
Anatomy and Physiology of Blood and Lymph Flow in the Horse Leg
Blood travels to the horse’s limbs via arteries, delivering oxygen and nutrients to the tissues, then returns back to the heart via veins. The blood in the arteries is under pressure, which is determined by the heart rate, vascular resistance of the blood vessel and blood fluid volume. This pressure drops once the blood begins to return to the heart in the veins. Given the lack of significant pressure to assist the flow back to the heart, it is generally accepted that movement and pressure within the equine foot, actually serves as a heart, helping to pump the blood back up the leg. Horses are often referred to as having 5 hearts, implying a true heart in the chest and one heart per foot.
Fluid tends to shift out of the blood vessels, nourishing the tissues as part of normal physiologic processes. In some cases, due to poor return of blood via the veins to the heart, fluid can back up in the blood vessels, and begin to actually ‘weap’ out into the surrounding tissue, adding more fluid to the equation. In either case, most of this fluid outside of the blood vessels is generally taken up by the lymphatics, which are similar to blood vessels, and then returned back to the heart to be rejoined with normal blood circulation.
When we have a horse with a swollen leg, in most cases this implies that fluid has accumulated in the tissue outside of the blood vessels. Often, we will use the term ‘edema’ to refer to this fluid accumulation. If we put pressure to the swollen tissue or leg with our thumb, it will often leave an indendation, almost like mashing dough. The leg or swollen area will also be tight, but in regards to overt pain, it can be variable. So, we know that when we have a swollen leg, it is fluid accumulation, technically stocking up, but the cause is not always the same.
Causes of Leg Swelling in the Horse
The term “Lymphangitis” refers to overt inflammation within the lymphatic system, leading to non-functional or compromised lymphatics, often blocked or damaged. This inflammatory process then impairs normal fluid circulation by the lymphatics and in the end, fluid pressure builds within the lymphatics and then weaps out into the surrounding tissue. Lymphangitis is not only an inflammatory process but usually connected with a bacterial infection. Advanced cases of Strangles in the horse can lead to lymphangitis as can other bacterial infections.
The term “cellulitis” refers to inflammation within the soft tissue of the leg, including muscle tissue. This condition is often secondary to a wound or spread of a bacterial infection from another location within the body. Again, here we have inflammation and infection in most cases, but involving soft tissue structures. The swelling within the soft tissue actually can impair blood and lymphatic circulation, just from shear constriction, leading to increased pressures and poor blood and fluid flow. The category of cellulitis to me also includes general wounds to the leg, which can be lacerations or even soft tissue injuries. Dependent on the extent of these injuries, blood vessels and/or lymphatics can be involved with resultant damage. Inevitably, this leads to fluid accumulation outside of the lymphatics and blood vessels, leading to the swollen leg.
The term “lymphedema‘ is a general term to imply fluid accumulation or retention, without an inflammatory or infectious cause, leading to a stocked up appearance or swollen leg. These patients are usually chronic, stocking up after a night’s stay in the stall, no pain or lameness but resolving after turnout or increased work.
There are other causes of fluid accumulation or edema in the legs of horses. Again, we have to remember that we are dealing with the cardiovascular system and fluid which abides by certain physiological laws of nature. First, if the heart is not functioning correctly or there is overall poor circulation within that horse, fluid will likely accumulate as a result. Second, fluid is retained within blood vessels based on oncotic pressure, which is dictated by certain proteins including one in particular called albumin. Albumin generally holds fluid within the blood vessels and when albumin levels drop, for whatever reason, fluid generally will leak out of the vessels into the surrounding tissue. Albumin is a protein made by the liver from protein taken in from the diet. In cases of liver problems, severe infection, endotoxemia, low protein diets and starvation, it is not uncommon to find swollen legs. However, in cases of low albumin, we will also generally see fluid accumulation on the underside of the belly and sheath region in geldings.
Therapy Options for Stocking Up and Lymphedema in the Horse
All cases of fluid retention in the legs of the horse often improve with movement and pressure wraps. This includes situations of stocking up and lymphedema. Movement helps to increase heart rate and increases the rate of return of blood and fluid back to the heart. The more efficient the cardiovascular system, the more fluid that is absorbed and removed from the tissue space. Through movement, we are also moving the feet at a more rapid pace, which in turn helps to force blood and fluid back up the leg and towards the heart.
Pressure wraps also assist the problem in two ways. First, they help to force fluid in the soft tissue space back into the lymphatics and general circulation. Second, through their pressure, they also help to minimize fluid loss from the lymphatics and blood vessels. Caution should be noted in cases of impaired circulation however, as with too tight of a wrap or too prolonged use, one could actually impair or cut off circulation to the lower leg and digit. In most cases, pressure wraps are applied for 10-12 hours at a time, then off for 10-12 hours.
Water therapy is also helpful in many of these cases. In cases of infection and/or inflammation, cold hose water therapy is general very helpful at reducing some of the heat from the leg and pushing fluid back into the circulation. In cases of plain lymphedema, warm water therapy is more effective in my experience as often these cases are due to poor overall circulation and the added warmth appears to help improve or enhance circulation. This is analogous to cold hands in the winter time, which are often then pale in color. The cold temperatures actually make a weak circulation even weaker, disrupting and impairing blood flow, but if we add heat through gloves or otherwise, circulation is then enhanced, tissues warm up and color gets better.
Topical therapies are also helpful in chronic cases of stocking up and lymphedema, often including DMSO alone or combined with a steroid. DMSO is a great anti-inflammatory and antioxidant with tremendous healing potential. It many cases, it is combined with a steroid to help boost anti-inflammatory properties and used as ‘sweat’ under a breathable wrap. Usually, the sweat is applied for 10-12 hours, then removed for the next 10-12 hours along with cold or warm hose therapy.
In cases of inflammation and infection, often oral or injectable anti-inflammatory medications are also used along with appropriate antibiotics.
Outcomes and Options for Stubborn Cases of Stocking Up and Lymphedema
In most cases of infectious lymphangitis and cellulitis, the horses respond nicely to appropriate therapy and are not impacted negatively in the future. However, in some cases, long-term damage is done to the blood vessels, overall circulation and lymphatics due to the infection and uncontrolled inflammatory response. This can then lead to a long term tendency for fluid retention in that leg which can be difficult to manage.
I believe that cases of uncomplicated lymphedema or stocking up are usually the result of overall poor circulation. It is important in these cases to rule out liver problems via blood work and to evaluate the heart and blood pressure if possible. It is not uncommon to have older patients develop lymphedema as often with age, circulation and heart function becomes impaired on certain levels, impacting fluid circulation. I do think that in these cases, if there are no other health problems, they benefit from nightly standing wraps if stalled but ideally respond best to constant turnout where movement is encouraged.
Are there other options and means of controlling the problem? I think there are, personally.
Stocking Up and Cellulitis in the Horse; Look at the Breed!
When it comes to stocking up, lymphedema, and cellulitis in the horse, there are many pathways which lead to the creation of the problem. However, no one remedy will often work for every horse because they are different in their presentation and underlying cause. Correct the cause and you will correct or improve the situation. One of the biggest things is to look at your horse’s breed.
When it come to the horse, we really have two different types; easy keepers or more harder keepers.
The vast majority of horses with stocking up issues and cellulitis, at least in my experience, are your heavier breeds and those breeds are more prone to becoming easier keepers. They are heavier, stockier, and often have metabolic problems now or in the future. The root behind these guys is digestive health and the concept of ‘dampness‘. This is what we desire to target in our therapy.
In these heavier horses, I generally recommend a combination therapy of the Cur-OST EQ Total Support and the Cur-OST EQ Tri-GUT formulas. If the swelling is marked and there are other signs of ‘dampness’ in the body, such as oily skin, preputial discharge, or loose stools, then I would recommend the Cur-OST EQ Tri-Guggul instead of the EQ Tri-GUT.
In the cases of the harder keepers, which are usually the hotter natured horses who are thinner and more full of energy, the approach is slightly different. In these cases, we desire to combat inflammation and cool the body down a bit, while also addressing gut health. Here, we would recommend a combination of the Cur-OST EQ Plus and the Cur-OST EQ Tri-GUT.
If there are indications of infection, as in cellulitis, then we would add in the Cur-OST EQ Immune Full Spectrum for added immune and gut health support. Through this combined approach, we are able to help balance the inflammatory response, address gut health, and enhance the immune response, aiding potentially with clearing of the infection. It is not uncommon in these cases to have an unresolved infection persist for months to years with a likewise swollen leg and impaired fluid circulation. Even in these chronic cases, I have found the combined regimen of Cur-OST formulas has made a huge difference, especially when combined with topical sweat therapies.
Chronic lymphedema cases can prove more difficult. There are several thoughts on these cases, as again, they are usually associated with overall poor circulation. Assuming that liver and cardiovascular function is normal, we have found a few regimens have been helpful. Many cardiovascular and circulation problems in humans have been noted to be strongly associated with inflammation on many levels. Persistent inflammation in the body can impair circulation by altering the function of nitric oxide, which is a gas produced by the body which dilates and opens blood vessels. I have found that the use of our Cur-OST EQ Total or EQ Plus can benefit these cases, helping again to balance the inflammatory response. Considering that we are looking to improve nitric oxide levels to enhance circulation, the Cur-OST EQ Nitric Boost formula has also proven beneficial due to inherent nutrition and also the high level of nitrates which are used by the body to produce nitric oxide.
With all horses that stock up or have cellulitis, there are two other factors which must be addressed.
- The diet must be evaluated, removing grains and synthetic based supplements which include vitamin and mineral balancers. These are creating more gut and inflammatory problems.
- The horse must be exercised routinely or at least hand walked daily to stimulate circulation.
In the end, stocking up in the horse is a frustrating condition but a result of many possible origins or causes. Given the numerous causes and considering long term lingering damage from prior conditions, the options for therapy are really endless. Sometimes, though, as much as we wish for the first therapy to be the winning ticket, it doesn’t work out that way and more investigative work is needed to explore other options.
I hope this information helps.
Tom Schell, D.V.M.
Nouvelle Research, Inc.
www.nouvelleresearch.com
Great help, thank you. I’m an animal communicator, and one of my horses was having a lot of cellulitis flares last year, as well as EPM, and one day we were walking through the woods, and he was sniffing the ground like a hound dog, and when I asked him what he was searching for he said ‘hawthorn’ – I had no idea what it was, if it grew here, or what it did, but after research, I learned about its benefits for the cardiovascular system. I purchased the leaves and berries, and for about three months he readily ate it out of my hand until he no longer wanted it, and he hasn’t had a cellulitis flare since!