This case has been kindly provided by Dr. Claire Moiroud (DVM, DESV, Dipl. ECVSMR, Dipl. ACVSMR, ISELP Certified) from CIRALE (Centre d’Imagerie et de Recherche sur les Affections Locomotrices Equines – Normandy, France), part of the French National Veterinary School of Alfort (EnvA, France).
CIRALE is renowned worldwide as a reference center for the study of locomotor disorders and causes of underperformance in sport and racehorses. The facility has cutting edge imaging and rehabilitation equipment and is managed by renowned Pr. Fabrice Audigié and Pr. Jean-Marie Denoix.
HISTORY
• 12 year-old warmblood gelding
• Show Jumping (CSI4*, 145 cm)
• Mild right frontlimb (RF) lameness after a week-end of competition abroad + positive RF digital flexion
• Diagnosis: tendinopathy of the lateral angle of the superficial digital flexor tendon (SDFT)
> Treatment: PRP injections by the local veterinarian + rest
• Control by the referring veterinarian 2 weeks later: enlargement of the lesion on the ultrasonographic examination
> Box rest + topical treatment (NEXEN ND) + referred to the center for balneotherapy 2 weeks later
CLINICAL EXAMINATION AT ADMISSION
Admission = M1 from initial diagnosis of the SDFT tendinopathy
Physical examination
• Mild thickening of the palmaro-lateral aspect of the distal third of the right metacarpal area
• Mild sensitivity at palpation of the RF SDFT
Dynamic examination
• No lameness at walk and trot in straight line on hard ground
IMAGING AT ADMISSION
Admission = M1 from initial diagnosis of the SDFT tendinopathy
Ultrosonographic examination
• Lesion of the lateral angle of the RF SDFT
– Tickening + hypoechogenicity more marked in the distal third just proximal and at the level of the manica flexoria
– Presence of a mild Doppler signal at the maximum of the lesion
• Metacarpal fasciitis at the level of the lesion of the SDFT
– Presence of a Doppler signal => active inflammation
REHABILITATION PROTOCOL
- Activity
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Aquatic exercise: 6 weeks
> Swimming:
> Underwater treadmill: |
REHABILITATION PROTOCOL
- Activity
- Other exercise: 6 weeks
> Walking with uphill slope:
• 2 to 3 times a week with progressive increase of the duration of the session (max = 25 min) and the slope (4 to 6°)> Small paddock (sand) outings during the day from the second week + grazing in hand
TREATMENTS DURING HIS STAY
• Topical treatment for the first 3 weeks
• NEXEN ND: daily at the level of the lesion 10 days, then each other days, 10 days
• Low frequency ultrasound therapy for the last 3 weeks
> 3 times a week, on the distal third of the palmar metacarpal area more focused on the palmaro-lateral aspect
> half time on weight-bearing limb / half time on flexed limb with each transducer
| – 1st treatment : o Blue transducer: 80-85% power output, 5 min o Grey transducer: 90% power output, 5 min . – Then: o Blue transducer: 90% power output, 5 min o Grey transducer: 90% power output, 5 min . – Last week: addition of treatment with the red transducer, 80% output power, 5 min, twice a week before the other 2 (blue and grey transducers) |
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OUTCOME AT THE END OF THE STAY
Stay = 6 weeks, from M1 to M2,5 from the initial diagnosis of the lesion
OUTCOME AT THE END OF THE STAY
– Clinical evolution
| • From the second week: disappearence of the SDT sensitivity on palpation
• Mild increase of the palmaro-lateral thickening of the distal third of the metacarpal area at week 2 and 3 • Progressive decrease of the palmaro-lateral thickening of the distal third of the metacarpal area with ultrasonotherapy (+ stop of the topical treatment), slightly decreased compared to the admission examination • Stability of the locomotion: no lameness at walk and trot in straight line on hard ground |
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OUTCOME AT THE END OF THE STAY
– Ultrasonographic evolution
| • Improvement of the echogenicity of the lesion of the SDFT + mild decrease of the thickening of the lateral angle
• Decrease of the intensity of the Doppler signal in the SDFT lesion • Decrease of the thickening of the metacarpal fascia + disappearence of the Doppler signal in the fascia => decrease of the inflammation |
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DISCHARGE INSTRUCTIONS AND FOLLOW-UP
Discharge instructions
• Depending on the evolution of the horse’s locomotion and the clinical controls performed by the referring veterinarian
> Progressive introduction of trot fractions over 4 to 6 weeks -> first begin on right rein
> Progressive introduction of slow canter in fractions from the 5th or 6th week after introduction of trot (M4) -> first begin to canter left rein in straight line
> Consider introduction of small jumps from M4,5-M5 after the initial diagnosis
• Work on soft and regular grounds, avoid deep grounds
• Monitoring of the physical signs of the RF tendon area every morning before work
.
Follow-up by the referring veterinarian
• Good evolution
• Horse return to his sport career 5 months after the initial diagnosis of the lesion at the same level (145 cm) !
DISCUSSION / CONCLUSION
- Positive effect of the ultrasonotherapy ?
• Seems to have enhanced the healing of the lesion
– Greater difference between US examinations at M2 and M2,5 = from the beginning of the low-frequency ultrasound treatment
– No or small US difference between M0,5, M1 and M2 examinations
– This type of lesion may remain hypoechogenic
.
• BUT, we have no control horse…
• Lateral angle SDFT tendinopathies mainly of good prognosis with quicker return to sportive career than core lesions of the SDFT tendinopathies
. - This rehabilitation protocol combining 3 exercises (swimming, walking in water and walking with uphill slope) and ultrasonotherapy was well tolerated and adapted for the first part of the rehabilitation of this horse with lateral angle SDFT tendinopathy
. - This whole management of the horse has been successful with a return to previous level competition after 5 months of rehabilitation
