Evaluation of poor performance in competition horses: A musculoskeletal perspective. Part 1: Clinical assessment

Lack of willingness to go forward freely, lack of power, shortened steps, stiffness of the cervical or thoracolumbosacral regions are common nonspecific signs of musculoskeletal causes of poor performance in sports horses. Understanding musculoskeletal causes of poor performance requires knowledge of how normal horses move, the requirements of specific work disciplines, the nomenclature used by riders to describe how a horse is performing and the interactions between horses and riders. Determining the underlying causes needs an in‐depth history and clinical assessment, including in hand, on the lunge and ridden. Ridden exercise should include all aspects with which the rider is experiencing problems. Change of the rider can sometimes help to differentiate between horse and rider problems, but most normal horses are compliant and just because a horse goes better for a more skilled rider does not preclude an underlying pain‐related condition. Lungeing and ridden exercise should include not only trot but also transitions and canter which may highlight gait abnormalities not seen at trot. An accurate history combined with thorough clinical examination of the whole horse should permit the establishment of a list of problems requiring further investigation.     

Distribution of radiodense contrast medium after perineural injection of the palmar and palmar metacarpal nerves (low 4‐point nerve block): An in vivo and ex vivo study in horses

Reasons for performing study: Evidence‐based information is limited on distribution of local anaesthetic solution following perineural analgesia of the palmar (Pa) and palmar metacarpal (PaM) nerves in the distal aspect of the metacarpal (Mc) region (‘low 4‐point nerve block’). Objectives: To demonstrate the potential distribution of local anaesthetic solution after a low 4‐point nerve block using a radiographic contrast model. Methods: A radiodense contrast medium was injected subcutaneously over the medial or the lateral Pa nerve at the junction of the proximal three‐quarters and distal quarter of the Mc region (Pa injection) and over the ipsilateral PaM nerve immediately distal to the distal aspect of the second or fourth Mc bones (PaM injection) in both forelimbs of 10 mature horses free from lameness. Radiographs were obtained 0, 10 and 20 min after injection and analysed subjectively and objectively. Methylene blue and a radiodense contrast medium were injected in 20 cadaver limbs using the same techniques. Radiographs were obtained and the limbs dissected. Results: After 31/40 (77.5%) Pa injections, the pattern of the contrast medium suggested distribution in the neurovascular bundle. There was significant proximal diffusion with time, but the main contrast medium patch never progressed proximal to the mid‐Mc region. The radiological appearance of 2 limbs suggested that contrast medium was present in the digital flexor tendon sheath (DFTS). After PaM injections, the contrast medium was distributed diffusely around the injection site in the majority of the limbs. In cadaver limbs, after Pa injections, the contrast medium and the dye were distributed in the neurovascular bundle in 8/20 (40%) limbs and in the DFTS in 6/20 (30%) of limbs. After PaM injections, the contrast and dye were distributed diffusely around the injection site in 9/20 (45%) limbs and showed diffuse and tubular distribution in 11/20 (55%) limbs. Conclusions and potential relevance: Proximal diffusion of local anaesthetic solution after a low 4‐point nerve block is unlikely to be responsible for decreasing lameness caused by pain in the proximal Mc region. The DFTS may be penetrated inadvertently when performing a low 4‐point nerve block.     

Idiopathic hopping‐like forelimb lameness syndrome in ridden horses: 46 horses (2002–2014)

There has been no analysis of a hopping‐type forelimb lameness syndrome seen in ridden horses. The objectives of this retrospective study were to describe the clinical features of this syndrome, response to diagnostic analgesia and imaging findings and to document post mortem findings. Clinical records from 2002 to 2014 were reviewed and data concerning signalment, history, lame limb(s), lameness characteristics, response to diagnostic analgesia and diagnostic imaging were recorded. There were 46 horses from 4 to 13 years of age, 6 of which had a history of known or suspected trauma immediately before the onset of reduced performance or lameness. Lameness seen when ridden was characterised by an intermittent shortened cranial phase of the step of the lame forelimb at the trot and marked elevation of the head as the affected limb was protracted, with the horse appearing to ‘hop’ (on the contralateral limb) as if trying to break to canter. When lameness was at its worst horses were unwilling to trot. Three horses showed sporadic severe stumbling. Local analgesia of the affected limb did not improve the lameness and in 16 horses lameness deteriorated. Three of 5 horses showed some improvement (≥2/8 grades) in the hopping‐type lameness after intra‐articular analgesia of the articular process joints of the sixth and seventh cervical vertebrae, ipsilateral to the lame forelimb. Radiographic, ultrasonographic and nuclear scintigraphic examinations were inconclusive. Two of 4 horses responded to treatment with gabapentin. In 3 horses post mortem examination revealed mild lymphocytic inflammation within or around the dorsal root ganglia of the fifth and sixth cervical nerve roots, sixth cervical nerve root or second thoracic nerve root ipsilateral to the lame limb. Idiopathic hopping‐type lameness syndrome in ridden horses may be a pain‐related condition ± a neurological component and currently has a guarded prognosis.     

Crooked tail carriage in horses: Increased prevalence in lame horses and those with thoracolumbar epaxial muscle tension or sacroiliac joint region pain

The relationship between lameness and crooked tail carriage (CTC) in horses is unclear. The objectives of this study were (i) to determine the association between CTC and lameness; (ii) among lame horses, to determine associations between CTC and lameness diagnosis, saddle slip, thoracolumbar range of motion (ROM), epaxial muscle tension and pain, and sacroiliac joint region (SIJR) pain, and (iii) to determine whether abolition of lameness and SIJR pain by diagnostic anaesthesia modified CTC. In this study, 520 lame and 170 nonlame sports horses were examined for CTC and other characteristics by one clinician (S.J.D.). All horses were evaluated when ridden. Lame horses were also assessed in hand and on the lunge. Crooked tail carriage, its direction, lameness, musculoskeletal and tack-related parameters were recorded as binary variables and analysed using 2 × 2 contingency tables. Sacroiliac joint region pain was diagnosed using local anaesthesia. Standard errors are shown in square brackets. 32.5% of lame horses had CTC, compared with 5.3% of nonlame horses (odds ratio = 8.6 [confidence intervals 4.4, 16.7]; P = 2×10⁻¹²). Of 169 lame horses with CTC, 103 (60.9% [3.8%]) held their tail to the left. There was no association between the side of the predominant lame limb and CTC direction. However, CTC was more common (P = 0.005) in horses with hindlimb lameness (35.7% [2.4%], N = 401) compared with forelimb lameness (21.0% [4.1%], N = 100). Crooked tail carriage was associated with SIJR pain (P = 0.0007) and thoracolumbar epaxial muscle tension (P = 0.0007), but not with saddle slip, reduced thoracolumbar ROM or thoracolumbar epaxial muscle pain. Limitations of the study included the facts that nonlame horses were a convenience sample and lameness assessment, other clinical observations and determination of the presence of CTC were subjective, with potential for bias. Video recordings and photographs are available for verification of tail position. It was concluded that CTC is more prevalent in lame horses than nonlame horses. There is a positive association between CTC and hindlimb lameness, SIJR pain and thoracolumbar epaxial muscle tension.     

A comparative study of proximal hindlimb flexion in horses: 5 versus 60 seconds

Reasons for performing study: The flexion test is routinely used in lameness and prepurchase examinations. There is no accepted standard for duration of flexion or evidence that interpretation of results would differ with different durations of flexion. Hypothesis: There will be no difference in interpretation of proximal hindlimb flexion for 5 or 60 s. Methods: Video recordings of lameness examinations of 34 client‐owned horses were performed that included: baseline lameness, proximal hindlimb flexion for 60 s, and flexion of the same limb for 5 s. Videos were edited to blind reviewers to the hypothesis being tested. The baseline lameness video from each horse was paired with each flexion to make 2 pairs of videos for each case. Twenty video pairs were repeated to assess intraobserver repeatability. Fifteen experienced equine clinicians were asked to review the baseline lameness video followed by the flexion test and grade the response to flexion as either positive or negative. Potential associations between the duration of flexion and the likelihood of a positive flexion test were evaluated using generalised linear mixed models. A kappa value was calculated to assess the degree of intraobserver agreement on the repeated videos. Significance level was set at P<0.05. Results: Proximal hindlimb flexion of 60 s was more likely to be called positive than flexion of 5 s (P<0.0001), with the likelihood of the same interpretation 74% of the time. The first flexion performed was more likely to be called positive than subsequent flexions (P = 0.029). Intra‐assessor agreement averaged 75% with κ= 0.49. Conclusions: Proximal hindlimb flexion of a limb for 5 s does not yield the same result as flexing a limb for 60 s. Potential relevance: Shorter durations of flexion may be useful for clinicians that have good agreement with flexions of 5 and 60 s.     

Concurrent proximal suspensory desmopathy and injury of the proximal aspect of the accessory ligament of the deep digital flexor tendon in forelimbs or hindlimbs in 19 horses

Clinical features of proximal suspensory desmopathy (PSD) and concurrent injury of the proximal aspect of the accessory ligament of the deep digital flexor tendon (ALDDFT) have not been documented. The objectives were to describe clinical signs and diagnosis. This was a retrospective study. Patient details, lame limb(s), response to diagnostic analgesia, and radiographic and ultrasonographic findings were recorded. PSD and injury of the proximal aspect of the ALDDFT were identified in 19 horses, 14 with forelimb lameness (unilateral 5, bilateral 9) and 5 with hindlimb lameness (unilateral 2, bilateral 3). Localising clinical signs were seen in 7/31 lame limbs (subtle thickening in the region of the ALDDFT [n = 3], pain on palpation of the body of the suspensory ligament (SL) [n = 6], heat in the proximal metacarpal or metatarsal region [n = 2]). Forelimb lameness was abolished by perineural analgesia of the palmar metacarpal (subcarpal) nerves in 17/23 limbs. In the remaining limbs intra‐articular analgesia of the middle carpal joint (n = 2) or an ulnar nerve block (n = 4) were required to eliminate the lameness. Hindlimb lameness was abolished by perineural analgesia of the deep branch of the lateral plantar nerve (n = 2) or local infiltration of the proximal plantar aspect of the metatarsus (n = 3); a tibial nerve block resolved lameness in the remaining 3 limbs. Lesions of the SL and of the ALDDFT were characterised ultrasonographically by enlargement, heterogeneous echogenicity and loss of long linear echoes in longitudinal images. In 3 horses adhesions between the ALDDFT and the SL were identified post mortem. Close apposition of these structures seen ultrasonographically may indicate adhesion formation. It was concluded that the clinical features of PSD and concurrent injury of the ALDDFT are similar to those for PSD alone, highlighting the need for comprehensive and systematic ultrasonographic assessment.     

High-field magnetic resonance imaging investigation of distal border fragments of the navicular bone in horses with foot pain

Reasons for performing study: Distal border fragments of the navicular bone can be seen in lame and nonlame horses and their clinical significance remains open to debate. Objectives: To describe the magnetic resonance imaging (MRI) appearance of distal border fragments and the adjacent navicular bone. To investigate the relationship between fragments and other abnormalities of the navicular bone and the distal sesamoidean impar ligament (DSIL). Methods: Horses were included if pain causing forelimb lameness was localised to the foot and high‐field MR images were acquired. The size and location of distal border fragments were recorded. Abnormalities in the adjacent navicular bone were graded to obtain a fragment grade. A total navicular bone grade was assigned. The DSIL was also graded. A Chi‐squared test was used to test for associations between the presence of a fragment and specific lesions involving the distal border of the navicular bone, the total grade of the navicular bone, and the grade of the DSIL. Results: 427 horses were included and 111 fragments observed. There was a significant association between the presence of a fragment and the total navicular bone grade, osseous cyst‐like lesions, increased number and size of the synovial invaginations of the distal border, increased signal intensity on fat suppressed images and size of distal border entheseophytes. Conclusions: There is an association between distal border fragments and other pathological MRI abnormalities of the navicular bone. Potential relevance: Distal border fragments are part of navicular disease, but their contribution to pain and lameness remains to be clarified.     

Muscle strain injuries of the hindlimb in eight horses: diagnostic imaging,management and outcomes

Objective To describe the clinical presentation, ultrasound findings, management and outcome in horses with muscle tear injuries of the hindlimbs. Design Retrospective case series Procedure Medical records of eight horses were reviewed and information on signalment, history, presenting complaint, physical examination findings and further diagnostic tests were recorded. Diagnosis of muscle injury was determined by the presence of abnormal ultrasound findings, compared with the contralateral limb, and, when required, nuclear scintigraphy. Follow-up information was obtained via telephone interviews with owners, trainers and referring veterinarians. Results Muscle tears causing lameness were identified in the middle gluteal (3), semitendinosus (1), semimembranosus (2) and gracilis (2) muscles. Tears were classified by ultrasound imaging as partial (6) or complete (2). The degree of lameness did not appear to be indicative of the extent of injury or of completion of healing. Long-term follow-up was available for seven horses and the outcome was favourable in six cases. Conclusions and clinical relevance Ultrasonography is useful in the diagnosis and assessment of moderate to severe muscle strain injuries. The prognosis appears to be favourable in most cases, although recurrence of injury and lameness can delay the return to athletic activity and an inferior outcome with persistent gait abnormality may occur.     

Application of a Ridden Horse Pain Ethogram to horses competing at 5-star three-day-events: Comparison with performance

A Ridden Horse Pain Ethogram (RHpE) was previously developed to facilitate the detection of musculoskeletal pain. The objectives were to apply the RHpE during warm-up for the dressage phase of two 5* three-day events and to correlate the RHpE scores with subsequent performance. It was hypothesised that there would be a higher rate of failure to complete the cross-country phase in horses which exhibited ≥7 behaviours compared with those showing <7 behaviours. The RHpE, comprising 24 behaviours, was applied for 10–12 min during warm-up. Gait abnormalities in trot and canter were recorded. Dressage penalties, cross-country performance, showjumping penalties and final placings were documented. Horses were categorised as those which completed cross-country, or those which did not complete because of elimination or retirement. RHpE scores (n = 137) ranged from 0 to 9/24 (median 3 [range 0–9] for nonlame horses; median 5 [range 1–9] for horses with gait abnormalities in trot or canter). There was a moderate correlation between dressage penalty scores and the RHpE score (rho = 0.4, P<0.001, Spearman rank). Fifty-nine per cent of horses (n = 10/17) with a RHpE score ≥7 failed to complete cross-country, compared with 33% (n = 39/117) with a score <7. Horses that failed to complete the cross-country phase had higher RHpE scores compared with those that completed (P = 0.04, W = 8.3, Kruskal–Wallis; pairwise comparison Bonferroni, P = 0.06). There was a significant (rho = 0.3) relationship between total RHpE score and final horse placings (n = 80, P<0.01, Spearman rank). Horses with lameness or gait abnormalities in canter had significantly higher RHpE scores (P<0.01, χ² = 35, chi-square test) compared with other horses. There was a strong correlation between the RHpE scores for horses which competed at both events (P<0.001, rho = 0.6, Spearman rank). The RHpE should facilitate earlier identification of horses which may benefit from diagnosis and treatment, resulting in improvement in both performance and equine welfare.     

A review of normal radiographical variants commonly mistaken for pathological findings in horses

A normal variant is an atypical finding present in a percentage of the population that generally has no clinical significance and is considered within the spectrum of normal findings. Normal variants are recognised upon gross anatomical dissection and also observed radiographically. Understanding the range of normal variants is essential for proper radiographical interpretation. This ensures that these variants are not mistaken for pathological lesions and helps avoid radiographical misdiagnosis. Common sites of normal anatomical variation in the foot, pastern, carpus, tarsus, elbow, shoulder and axial skeleton are reviewed.     

Review of glucocorticoid therapy in horses. Part 2: Clinical use of systemic glucocorticoids in horses

This article is the second in a review series about the use of glucocorticoids to treat medical and musculoskeletal conditions in horses. This segment in the series summarises reported dosages, methods of administration and the efficacy of glucocorticoids for various systemic diseases in equids. The most common use of systemic glucocorticoids reported in the literature for management and treatment of alterations of the respiratory, integumentary, immune and neurological systems are included.     

Clinical features and diagnosis of sacroiliac joint region pain in 296 horses: 2004–2014

There has been no large‐scale study of the clinical signs of sacroiliac (SI) joint region pain and its association with lameness and/or thoracolumbar pain. Horses with a positive response to infiltration of local anaesthetic solution around the SI joint regions (SI block) and/or abnormal radiopharmaceutical uptake (RU) in the region of the SI joints were included. History, clinical signs, diagnostic imaging findings, response to SI block, and concurrent lameness and/or thoracolumbar pain were recorded. Horses (n = 296) were divided into 2 groups: SI joint region pain only (Group 1, n = 43) and SI joint region pain and concurrent source(s) of pain (Group 2, n = 253). Clinical signs in Group 1 included increased tension in the longissimus dorsi muscles (40%), restricted flexibility of the thoracolumbar region (44%), trunk stiffness during exercise (61%) and poor hindlimb impulsion (56%). When ridden 65% had a poor contact with the bit, in 81% canter quality was worse than trot, and 35% bucked or kicked out with a hindlimb during canter. In both Groups 1 and 2 clinical signs were seen in a significantly greater proportion of horses during ridden work than lungeing (P<0.0001). Following SI block, 98% of horses showed dramatic improvement in clinical signs, including greater overall movement through the trunk, increased hindlimb impulsion and better quality canter. Abnormal RU in the SI joint regions was seen in 85/180 (47%) horses. Of horses with a positive response to SI block that underwent scintigraphy, only 43% had abnormal RU. Per rectum ultrasonographic examination of the SI joint region revealed abnormalities in 41/129 (32%) horses. Clinical signs of SI joint region pain are worse when horses are ridden. Sacroiliac joint region diagnostic analgesia is a useful, safe but nonspecific block. Ultrasonography and scintigraphy can provide additional information in some horses, but negative results do not preclude SI joint region pain.     

Comparisons of computed tomography, contrast-enhanced computed tomography and standing low-field magnetic resonance imaging in horses with lameness localised to the foot. Part 2: Lesion identification

Reasons for performing study: No previous study compares computed tomography (CT), contrast‐enhanced computed tomography (CECT) and standing low‐field magnetic resonance imaging (LFMRI) to detect lesions in horses with lameness localised to the foot. This study will help clinicians understand the limitations of these techniques. Objectives: To determine if CT, CECT and LFMRI would identify lesions within the distal limb and document discrepancies with lesion distribution and lesion classification. Methods: Lesions in specific structures identified on CT and MR images of feet (31 limbs) from the same horse were reviewed and compared. Distributions of lesions were compared using a Chi‐squared test and techniques analysed using the paired marginal homogeneity test for concordance. Results: Lesions of the deep digital flexor tendon (DDFT) were most common and CT/CECT identified more lesions than LFMRI. Deep digital flexor tendon lesions seen on LFMRI only were frequently distal to the proximal extent of the distal sesamoid and DDFT lesions seen on CT/CECT only were frequently proximal to the distal sesamoid. Lesions identified on LFMRI only were core (23.3%) or splits (43.3%), whereas lesions identified only on CT were abrasions (29.8%), core (15.8%), enlargement (15.8%) or mineralisation (12.3%). Contrast‐enhanced CT improved lesion identification at the DDFT insertion compared to CT and resulted in distal sesamoidean impar ligament and collateral sesamoidean ligament vascular enhancement in 75% of cases. Low‐field MRI and CT/CECT failed to identify soft tissue mineralisation and bone oedema, respectively. Conclusions and potential relevance: Multiple lesions are detected with CT, CECT and LFMRI but there is variability in lesion detection and classification. LFMRI centred only on the podotrochlear apparatus may fail to identify lesions of the pastern or soft tissue mineralisation. Computed tomography may fail to identify DDFT lesions distal to the proximal border of the distal sesamoid.