Proximal soft tissue injuries Flashcards
Carpal and tarsal sheath injuries
Usually present with lameness and effusion…
Ultrasound is the logical first line diagnostic tool, but don’t overlook the value of radiography!
Peroneus (or Fibularis) Tertius injuries
An important part of the reciprocal apparatus
Classic clinical signs – can extend tarsus without the stifle.
Usually do well but lengthy rehabilitation period
Injuries of the patellar ligaments
An unusual cause of primary lameness
Easily diagnosed with ultrasound
Good prognosis for return to exercise
Long (12 month) rehabilitation period
Delayed patellar release - “locking stifle”
Most commonly seen in miniatures
Sometimes associated with weakness/poor muscling
Rehab for mild cases
Medial PL desmotomy for severe cases
The medial (and lateral) meniscus
A fairly common cause of stifle lameness
Often seen with other pathologies
Severe disease can be diagnosed with ultrasound
Mild-moderate disease is an arthroscopic diagnosis
Less favourable prognosis
Cruciate ligament injuries
Associated with acute, severe lameness
Some descriptions of US diagnosis
Arthroscopy is best diagnostic
Not always associated with effusion
Cruciate ligaments are extra-synovial
Not always a satisfying blocking pattern
Often only partially improve
When is surgery indicated for proximal limb soft tissue injuries?
for synovial structures:
* Navicular bursa
* Digital flexor tendon sheath
* Carpal/Tarsal sheath
* Stifle joint
What can be achieved surgically in proximal limb soft tissue injuries?
Excellent diagnostic ability
Sound prognostication.
Debridement of torn soft tissues – improved outcomes
What are the most likely foci of disease in the tarsal region?
Proximal suspensory ligament
Tarsometatarsal joint
Imaging choices for the tarsal area
Can be helpful to block each structure in turn, but takes multiple visits
Compromise -> can acquire images of both
First line treatments for the tarsal region
We can use the proximity of the joint to the proximal suspensory ligament to deliver medications
Medication of the tarsometatrsal joint can successfully manage the condition in some cases
Has the added benefit of also managing any concurrent small tarsal joint disease
What is a Neurectomy of the Deep Branch of the Lateral Plantar Nerve and Plantar Fasciotomy used for?
For refractory cases
A specific treatment for the proximal suspensory ligament
A popular surgical procedure for a more “curative” therapy
Neurectomy -> permanent (usually) desensitisation of the ligament
Fasciotomy -> allows the ligament to swell outwards overcoming compartment syndrome
Indications for Neurectomy of the Deep Branch of the Lateral Plantar Nerve and Plantar Fasciotomy
Improves to block of DBLP but not TMT
Failed first line treatments – usually intra-articular corticosteroids in the TMT
Choose individuals with good conformation and ligament integrity
Discuss competition legality
Contraindications for Neurectomy of the Deep Branch of the Lateral Plantar Nerve and Plantar Fasciotomy
Horses with marked ligament degeneration -> the procedure can accelerate ligament degradation
Competition legality -> currently falls into same category as palmar digital neurectomy
Candidates for biological treatments of the proximal limb
Tendons with core lesions
Injuries within synovial structures
Aims of biological therapies in the proximal limb
Reduce inflammation,
improve extracellular matrix quality,
improve functionality of scar tissue,
Reduce healing time,
reduce re-injury
Autologous stem cells
Bone marrow derived
Adipose tissue derived
Culture takes 2 weeks
Allogenic stem cells
“off the shelf” products
Currently out of production
PRP
Protein rich plasma
Autologous product:
Blood sample obtained
Centrifuged
Plasma removed
Filtration systems also exist
Quick to make
Some questionable evidence
Controlled exercise programs for proximal limb rehab
Consistently improve outcomes
“best practice”
LOTS of variation in programs prescribed- needs to be tailored to the individual case and situation
Pattern of increasing exercising intenstiy for controlled exercise rehab
Walking in hand or under saddle
Trotting under saddle in straight lines
Trotting under saddle on circles and bends
Canter work in straight lines
Canter work on circles and bends
Rehab techniques
Exercise programs
Extracorporeal shockwave therapy (ESWT)
Laser (class 4)
Cold/heat treatment
Therapeutic ultrasound
Pulsed magnetic field therapy
Shockwave therapy for rehab of proximal limb
Delivery of high-pressure waves to tissues - probably most focused at the junction between soft tissue and bone
Shockwave seems to temporarily improve lameness, but has limited effects on structure and function
How many shocks are usually used for shockwave rehab therapy
1000-2000 per site
Patient preparation for shockwave therapy
Restraint – sedation
Clipping long haired horses
Application of acoustic gel
Delivered when non-weightbearing
Protocol of shockwave therapy
Often delivered weekly/fortnightly
Treatment period of 4-6 weeks
Not within 5d of FEI competition!
Class IV laser therapy for proximal limb rehab
Reduce lesion size,
increase doppler signal,
change collagen deposition,
improve US fibre pattern
No evidence (yet!) that this leads to reduced re-injury rates!
Contraindications for the use of high powered (class 4) lasers
Eye exposure,
neoplasia,
haemorrhage,
pregnancy?
sex glands?
Methods to improve equine core stability
Water treadmill exercise
Swimming
Ridden or in-hand exercises
Whole body vibration (lacking evidence!)
Benefits of water treadmill
Adds resistance to cranial phase of stride
Increases limb retraction (stride height)
Increases ROM of the axial skeleton
Buoyancy (if deep enough…)
Clinical use of the water treadmill
Can be prescribed as an intensive course or incorporated into ongoing training
When is swimming recommended?
Aerobic fitness
Brachiocephalicus tone
Reducing stress on joints and soft tissues
Clinical use of swimming
Largely used in the training and rehabilitation of thoroughbred racehorses (improved fitness and reduced repetitive strain)
Less useful for sports horses as it encourages an extended neck and thoracolumbar spine – the opposite of what we hope to achieve!!
Consider implications for a fit horse with reduced bone stimulation…
RIdden and non-ridden rehab
Lunging and long-lining devices
Hill work (trot up and walk down)
Pole exercises (raised)
Working on a range of surface types
“cross training”
