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.
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.
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.