Patient History Report

Today in the mail I received the patient history report on Sinwaan's visit from 9/17/13. I really love my vet clinic and working with both Dr Pritchett and Dr Ferris so far. I think mailing me the report goes above and beyond anyone I have worked with in the past, and it is really nice to have it all in writing since it is so hard for me to digest and remember everything as it is happening.

Sinwaan is an Arabian gelding who is 16 yr & 6 mo, DOB 3/10/1997. Weight listed as 1,050.

Lameness Exam
History: Previously seen for a left hind limb lameness due to wearing off the toe. He has been on a bute trial since the last visit on 9/6 and has been resting in his paddock. No other treatments have been performed. The original goal was to ride in a 50 mile endurance ride in October. He has been unshod since the last exam because he pulled the left hind shoe.
S: Today Sinwaan is still BCS approximately 6-7/9. He has mild withdrawal response to palpation of his right and left thoracic and lumbar longissimus muscles bilaterally, but is not positive to compression of his tuber sacrale. There is mild thickening of the joint capsule of the femoropatellar joints and mild effusion of the same bilaterally. He has very straight conformation in his hind limbs through the stifle and hock, with an extended fetlock. His hocks palpate slightly abnormal on the medial aspect of both, with potential mild remodeling over the distal intertarsal and tasometatarsal joints. Hoof tester exam of all four feet was unremarkable except for bridging the medial frog the lateral heel bulb of the left front foot which was mildly positive. On lameness examination, he slightly circumducts the left hind limb when walking, and tracks with the right hind limb more to midline. At the trot he was 3+/5 lame on the left hind at the trot and the lameness is referring to left front. Occasionally he takes a step that appears to be sensitive to the rocks due to being barefoot. The left hind limb lameness is worse when the limb is on the inside of the circle, vs. outside.
Flexions:
Distal LH - mild positive
Stifle LH - moderate positive
Full LH - moderate positive (slightly worse than stifle)
Distal RH - mild positive
Stifle RH - mild positive - appeared symmetrically lame on both limbs
Full RH - moderate positive - switched to primary RH limb lameness for several strides, then returned to the baseline LH limb lameness.

Diagnostic blocks, radiographs and ultrasound were discussed. Due to Sinwaan's straight hind limb conformation, there is some concern that there could be suspensory pain present. The decision was made to persue diagnostic blocking of the LH limb to rule out suspensory injury. Based on palpation of the hocks and the presentation of his lameness (worse on the inside of the circle, worse to full limb flexion, and moderately sensitive to back palpation, the next most likely cause of his lameness is pain in the DIT and TMT joints.

Low 4-point nerve block LH - no significant improvement.
Deep branch of hte lateral plantar nerve (proximal suspensory) LH - 70% improvement overall, improved when on the inside of the circle, left forelimb lameness improved as well (decreased referring lameness)

A light bandage with nitrofurazone was applied to the left hind limb.

Plan: Based on the improvement to blocking today, it is most likely that he has a suspensory injury. To assess the extent of this injury, an ultrasound of the metatarsus is recommended at a later time. Because of the blocking today there will be fluid and gas artifact in the tissues, which could confound visualizing a lesion. We will pursue ultrasounding him next month.

The bandage on the left hind limb can be removed tomorrow (Wednesday) and his leg rinsed in the hose to remove the nitrofurazone. Ideally, you should wear gloves or use a plastic bag to protect your skin from the nitrofurazone when removing the bandage.

Sinwaan should be rested in a small paddock for the next month until he can have the ultrasound performed. Ideally this should be no larger than approximately 14' x 24-36' so he cannot run if he likes to play in his pasture.

Pending the results of the ultrasound, using Platelet Rich Plasma to treat the suspensory and rehabilitation will probably have the best chance of returning Sinwaan to his previous performance. He will most likely need at least 4-5 months of rest and rehabilitation before returning to work under saddle.

Treatment with Firocoxib is worth considering for Sinwaan as he enters his rehabilitation phase. This is similar to bute but has fewer side effects for the gastrointestinal tract and kidneys when given long term. We can discuss this further on his next visit.

Thank you for bringing Sinwaan in to see me today. I look forward to seeing him next month.
Dora Ferris

Visit to the specialist

This week Dr. Dora Jean Ferris is in town so I took the opportunity and scheduled an appointment time with her for Sinwaan.

We did more lameness evaluations with flexion testing and it was more obvious today that he was "off." Dr Ferris pointed out to me that he is dropping his right hind lower to compensate for the pain on his left side.  Today he was even doing a little toe dragging without me riding him. (Obvious in the photo above). Another thing she pointed out to me was his muscles quivering in a specific spot, when flexing him, more so on the left than on the right. 

Video #1 - left flexion test

Video #2 - as a comparison, right flexion test

After these she did some more flexion tests, focusing more on the stifle area but my video camera was not recording when I thought it was. Oops.

Video #3 - starts at 10 sec. right flexion test on right

Video #4 - starts at about 18 sec. flexion test on left

Video #5 - flexion on right

Then she used a hoof tester and checked all his feet for any soreness issues. Other than some mild tenderness on the inside frog of the left fore, there were no issues.

Then we talked, or I should say, she talked to me about what she was seeing.  I will include the report in the next post because it covers the whole visit.

Thickening area

We had the options of blocking, radiographs and ultrasound. I asked her what option she would choose, if she could only do one (due to my financial limitations), and she said the blocking should give her the most answers today. The price quote for that was cheaper than the radiographs so I said let's go ahead. Well, they had another appointment due to come in within 30 minutes, and not wanting to get started only to be interrupted, they asked if I could leave him with them for a couple of  hours. I said that was no problem.

As we walked him back to his pen, we passed the cattle in the stocks. It was castration day for them, and there was quite a bit of blood, which they had warned us about before walking over there. Ellie was with me, carrying a armload of hay for Sinwaan, and I told her to watch Sinwaan, which she did. She told me later she did not see any blood,  but she wanted to know all about castration!  Sinwaan was settled into his stall next to a horse who was all bandaged up from injuries resulting from the storm we just had. Bandages all the way up two of his legs, stitches in his neck, but he was upright and looked like he was going to make it.

Exciting day at the vet clinic to be sure. I'll report more later after I pick him up.

Here we are again

Sinwaan watching neighboring cows. 

When his mane is at this angle he always reminds me of the Breyer Indian Pony

Monday Chad was able to come out and pull Sinwaan's shoes and give him a trim. I had leveled out an area by his water tank the day before and flooded it so his hooves would not be so hard. Chad said it worked perfectly, and I was glad when the improvement also meant he could remove that last nail still in the hoof without a shoe.

I figured this past week would drag by, but with school starting up again and all the other things that happen in our daily lives, it actually wasn't too bad. Before I knew it Friday rolled around and it was time to take Sinwaan back in for some more evaluations, and hopefully answers. 

The night before we had a wicked storm pass through, leaving many without power. Sinwaan's barn was one of the unlucky ones, so we hauled some water out to them on our way to pick him up.

Dr Pritchett and her tech, I believe Linda was her name, started out with a lameness exam in-hand. Using some of the same tests as last time, but taking it a step farther. I am not a Hollywood pro focus-puller so apparently it is impossible for me to get clear in-focus videos from this fancy camera, therefore I am only posting one from that session.

Video #1 - Flexion test. This one I could see he looked a little off.

Guess who took their saddle pad home to wash it, and forgot to bring it today? 

Thankfully Matt was able to deliver in record time.

After those tests it was time to saddle up so she could observe him under a load. At the walk there was no sign of toe drag, but at the trot it became obvious. I didn't get to do much riding, as it didn't take long to see the issue. 

Video #2 - Riding, about 3 minutes long. It was a little stressful riding him there after not having ridden for 2 weeks, with the highway next-door, but he was quite good. I felt like a dummy when I un-tacked and noticed I had never clipped the top portion of his breastcollar. Oh well!

After  un-tacking they did more evaluations. 

Video #3 - Trotting, circles. More focus issues, sorry!

Video #4 - Flexion test, trying to aim higher up in the leg/hip area I believe (and a video capture below to show what he thinks of this)

Then another flexion test aiming lower in the leg, but that video is not worthy of posting as the trotting away portion is nowhere near being in focus.

After that she performed the same tests on the opposite side.

There was mention of sedating him, not for x-rays this time, but for palpating his hip from the inside (lucky for all involved that was never needed). First, however, she wanted to do some more research. So after a quick trip inside the building she came out with a couple more ideas. More palpating, flexing, extending his hind leg...trying to locate the issue.

Video #5 - Palpations and a reaction on the left

In the midst of this Ellie told me she had to use the restroom, so I took her in. I came out to find Dr. Pritchett with a look of triumph on her face. "I found it." Confused, I asked her what she found. She showed me that when she palpated his stifle, right over the peroneal nerve, he would move away, lift his leg, and just generally looked uncomfortable. She did the same thing on the opposite side with no response. Palpating other neighboring areas on either leg, also no response. Definitely an issue in that one spot.

Later, when we were inside the building, Dr Pritchett brought out her anatomy book to show me what everything looked like in his leg where he is having that issue. Quite kind of her, and fascinating!

Palpation of the right stifle joint over the peroneal nerve caused no reaction, 

compared to the left side. 

Dr Pritchett has an equine sports medicine specialist colleague (Dora Ferris DVM) whom their clinic plans to work with, who just so happens will be in town next week with her own ultrasound equipment. Dr Pritchett said she would like to talk with Dr Ferris more about this case and perhaps she could offer an additional diagnosis or treatment plan. She plans to get back in touch with me next week after they have a conversation.

(Sidenote: because I am curious, and the internet is so powerful, I Googled Dr Ferris and found the following...she is also the daughter of two local vets;)

We also talked about how after some rest and anti-inflammatories we should be able to develop a conditioning plan for Sinwaan to help build up his muscles to get him back on track for distance riding. (For example, lounging work with ground poles to start with, not riding) She sent me home with some bute to be given 2x a day. The barn owners volunteered to give that, to save me all that driving. Thank you!

So although I didn't get a complete answer about what caused this, or how exactly we will fix it, or how long he will be on vacation, it does sound like there is hope, and it is better than the alternatives. Here's hoping Sinwaan is back to normal soon.

However, no October ride for him. And since so much of the ride is about the bond that we share, I am not sure I want to do it without him on another horse, even though I have already had a very kind offer. I should probably volunteer, and crew, and see it all from the other side.

* * *

Later that afternoon I called back to the clinic to ask about that nerve, because I had already forgotten the name of it, and couldn't seem to figure it out doing basic Google searches for "stifle nerve." The gal who answered the phone said she could email me the notes from the visit, which I thought was really awesome. You can see them below.

Using this basic format—Subjective and Objective observation, Assessment and Plan, the vet notes on Sinwaan from today's visit are as follows:

Lameness Exam
S: Sinwaan is here for re-evaluation of the left hind limb. His feet have been trimmed. He has not been ridden.

O: No obvious lameness at the walk or trot on the pavement. Circumducts hind limbs well when turned to the left. He is more hesitant when turned to the right (left hind leg on the outside)
When ridden no lameness or dragging of the toe noted at the walk. When ridden at the trot - drags the left hind toe.
Flexion test of the left hind tarsus and stifle w/o rider - no change in gait
Flexion test of the left coxofemoral joint with the tarsus and stifle in extension - lameness noted and a few strides of toe dragging at the trot.
Subsequent to these observations - deep palpation of the lateral aspect of the stifle joint (area over the peroneal nerve) caused consistent pain reaction (moves away from me, lifts hind leg, switches tail). Palpation of the same area on the right hind leg did not cause any reaction.

A: Grade I/IV lameness of the left hind at the trot. Painful on deep palpation of the lateral aspect of the left stifle joint. Potential injury to the peroneal nerve.

P: Advised rest and anti-inflammatory. Consult with orthopedic specialist in additional diagnostics and rehabilitation. Lori C. Pritchett, DVM)