Core Lesion on DDFT - are standing wraps 24/7 standard?

[Speedy_Alice]

My 11 year old typically sound and sturdy gelding stressed his DDFT in wet, deep footing on the last day of a show 2 weeks ago. He was slightly off at the trot two days afterwards; the vet saw nothing on radiographs, but ultrasound showed a core lesion, left hind deep digital flexor tendon.

I’ve never dealt with an injury like this, nor any injury that required standing wraps, and I’m wondering whether keeping standing wraps on 24/7 is typical with this kind of injury.

Recommended treatment from the vet: 1st week: daily hand walk 15 min, cold hose 20 min, apply Surpass (I’m using Voltaren), standing wraps 24 hours/day. Confined to stall w/ small 12/24 attached paddock. 2nd week: same, but hand walk 20 min/day. Vet thought he’d need about 5-6 weeks of rehab.

The swelling is better than it was last week, but his leg feels warm when I take the wraps off. Heating up the leg under wraps seems counterintuitive, considering I just cold hosed it.

Is this one of those things that has vastly differing opinions (I know, shocker, in the horse world…! )?

Thanks for any info/experience you can share!

[Demerara_Stables]

My vet also had my mare in a 24/7 standing wrap for a check ligament injury. I also wondered about the heat but she ended up healing well and is back to full work and still sound on it.

[Speedy_Alice]

Thank you - that’s encouraging to hear!

[fanfayre]

Huh…
My vet recommends 12 hours wrapped only, so 12 on/12 off, and no cold hosing, only icing for 20 minutes max 2 to 3 times per day if possible.
Remove wraps specifically for the reason you feel- prevents heat buildup in the leg, and not hosing because it softens the hoof wall, which could lead to increased susceptibility to hoof abscesses.

Take it for what you will

[Weluvhaha]

I currently have a horse that injured his deep digital flexor tendon when his leg got stuck in a hay net that the stablehand hung too low on a tree. (Barn owner’s fault, but that’s beside the point.). There were other injuries as well and he was in the hospital in a leg cast for 30 days. The DDFT injury started out as a small lesion, but because he got excited during his stall rest, that lesion turned into a tear. At that point, I sent him to professional rehab center.

Professional rehab looks like this: the horses are stall rested in a small stall. They are sedated 24/7 for weeks or months on end. It is just a very mild sedation to keep the silliness down. They are leg-wrapped snuggly 24/7. They are hand walked on flat, smooth hard surfaces (not concrete-hard. DG or unpaved road hard. Barn aisle-hard.) The stall has minimal shavings. There were stall mats with just enough shavings to prevent hock sores. No deep shavings or soft ground. (as a sidenote, the doctor at the hospital told me that no horses should have deep shavings. It is just not good for them.) It was extremely difficult to find the right environment. Some rehab centers look like insane asylums. I found a good one where his emotional/mental state was cared for.

Regarding the sedation: Three seconds of silliness can undo months of rehab, so taking the edge off their silliness with Ace or trazodone is really essential and it’s not something you want do after the fact. This is the difference between DIY care and rehab centers. Professionals have seen this movie many times and they just don’t take any chances. The horses are sedated on arrival. My horse was in a hospital for 30 days and he was on 100 mg of ace. He’s been on trazadone 2x daily for months. When he is not on trazodone, there is no rebound effect. It’s been nine months and he’s been on Ace or Traz for all that time to no ill effect. Mind you the sedation is not enough to make him sleepy. It just takes the edge off his excitability.

Regarding the wraps, he is wrapped 24/7. The wraps are extremely important — when patients have a moment of silliness, the wrap supports the tendon. And since you have no idea when that moment of silliness will happen, 24/7 is necessary. Also if they were to nick the back of their leg with a hoof that could also prove very serious. So bubble wrap it is.

Heat- if you’ve ever had a torn tendon or ligament, you know how good heat feels. When a body gets cold, blood vessels constrict. This is why your hands and feet get numb when you’re out in the cold. With a DDFT injury, you’re trying to increase blood flow to a tendon that receives a very little blood flow naturally. Blood is the throughway that carries away damaged tissue and brings in the building blocks of new tissue. It’s like a river; the cells are like little boats carrying material to and from the crash site. Now Imagine what happens to river traffic when the river flow is low. So you want to avoid him getting cold and tensing up, which narrows and constricts that river. you want to keep the blood flowing and so heat is good. (ask your Vet if regenerative light therapy is available.)

At the same time, you’re trying to reduce inflammation. Well, hold on there. You’re trying to reduce “too much” inflammation. that inflammation is the blood cells carrying away the damaged tissue; it is not entirely a bad thing. Don’t you want the damaged tissue carried off? It’s like a reconstruction project. Bulldozers have to go in and carry off the damaged cells before they can begin building with fresh new cells. The inflammation is like a traffic jam, the result of so many boats rushing to carry away the damaged tissue. It is completely natural; and healing cannot occur if those cells don’t get in there to carry away the necrotic tissue. But, you could imagine so many boats on a river that nobody can get through at all, right? even if they are all ambulance boats, If there are too many then nobody gets through. So while inflammation is an important PART of the reconstruction process, you don’t want it to get completely out of control where it actually cuts off other blood vessels (other roads to the construction site.) Inflammation is part of -not anathema to - the rebuilding process.

There is some research that icing and cold hosing injuries is actually counterproductive. That’s experimental research done on mice (in which the mice that were not iced healed faster than the mice that were iced ) but it has not trickled down to the medical community. It was featured in a New York Times article. Regardless, you don’t want inflammation to get so out of control that it constricts blood vessels or structures in the leg. For that reason, you want to reduce EXCESSIVE inflammation- So that the road stays open to the reconstruction site. Otherwise, heat is good, to carry in and out the building block materials.

My horse was never iced or cold hosed- not in the hospital and not at the rehab center.

[Weluvhaha]

Also surpass and Voltaren are not the same. Yes the active ingredient is the same. But the carrying agent- the stuff that carries the active ingredient- is different. One is meant to penetrate the thicker skin of the horse. They are not interchangeable.

[colorfan]

Just wondering to bank the information. In this type of situation is concern about softening the hoof the reason for not cold hosing? Could one wrapped the hoof in a plastic bag then hose?

[Scribbler]

My understanding of current recommendations in human health is that cold icing is useful right after the injury. Pop an ice pack on the sprained ankle or big bruise the day of the injury. It helps moderate the excessive swelling and pain. But you don’t keep using ice long term. You don’t ice your ankle a week later. You don’t ice a broken arm in a cast. After the first day or so, you just want support and rest. You can take painkillers if necessary

[Demerara_Stables]

FWIW I’ve never heard of abscess risk being a reason to not cold hose, and I’ve been instructed to cold hose by a lot of people, including a dozen or so vets.

[fanfayre]

Yes, softening of the hoof is the reason.
I suppose you could go to the effort of bagging the foot…
My vet’s instructions, and she goes to many vet conferences and exchanges information, so I have no reason to believe she is incorrect

[Kimstar]

There is no standing bandage on this planet that increases or aids the support functions of the stay apparatus of the equine leg - period. Standing wraps are useful for protection and for limiting the amount of swelling in the superficial tissues of the leg. Increased support is mechanically impossible with an ordinary leg wrap.

ETA: the largest sport horse vet clinic here in Southern Ontario just tells you to use Voltaren - they don’t even suggest that you use Surpass. And it works just fine.

[before_color]

OP, I’m sorry you’re in this situation. Soft tissue rehab can be tricky and nerve wracking.

Was the vet that diagnosed this injury your routine/home veterinarian? If so, I would highly advise taking your horse to a clinic to have a specialist (ideally a surgeon) to evaluate your horse. In my experience over the years and with several different soft tissue rehabs, I have found that a specialist is best.

If that is not an option, then another one worth exploring would be to reach out to Carol Gillis.

[Weluvhaha]

But does it? Your equine clinic has done a controlled, double blind study with placebo? I doubt it.

Conclusion: “ The present results imply that different skin formulations containing the same concentration of an active drug when used in a species different from that for which it has been designed are not necessarily equivalent or interchangeable, as they may not be able to deliver the same amount of drug into or through the skin.”

https://www.sciencedirect.com/science/article/abs/pii/S0737080611001031

Vets talk to the sales reps. I found Vets often don’t even read the studies that support their recommendations.

It’s also interesting to know that the FDA requires that products for animals don’t cause harm. It does NOT require that they actually work. So the Standard for FDA approval of animal pharmaceuticals is much lower than that for humans.

The “support” I referred to was momentary for a 1-3 second exacerbation. No, it’s not proven that wraps can help. But my vet and the rehab centers I used and visited had the horses like mine in wraps. That’s all I can say. Perhaps it was a hopeful precaution? Better safe than sorry? However, I will say that when I started wrapping the legs of an old horse who long had a bowed tendon, after months his tendon tightened up and the vet said it hadn’t looked that good in many years.

[Scribbler]

When I’ve had a sprained ankle or strained thumb or even after a cast taken off my arm, or a twinge in my knee, an appropriate wrap or brace has been very helpful. It reduces pain and makes the thing heal faster. Is it support per se? Can a tensor bandage really support a full grown adult? Or is it something about reducing range of motion so the injury isn’t aggravated?

[Kimstar]

Here, Voltaren isn’t sold by vets. It is available over the counter and drug stores, Walmart, Costco, etc. And it was developed for human use, so it is actually effective. It is also now available at double-strength effective ingredient. Surpass was/is sold by vets and is MUCH more expensive than Voltaren. As I said above, vets don’t even recommend using Surpass anymore as they just tell you to go buy Voltaren.

I am sorry you are having to go through this with your horse, but it sounds like it is a relatively minor injury compared to what can happen. A horse of mine bowed a front tendon at age 22 and had a greater than 50% tear. We had had an early snow that was very wet and it got balled up in his shoes causing him to hyper-extend the leg when he slipped. (He was due for snow pads the following week which would have prevented the injury.) He was not built to have tendon issues, and in fact, his front legs had been clean as a whistle up to that point. All I wanted was pasture soundness for him and I did DMSO/Furacin sweats to get the initial swelling down and wrapped him for many months afterward. We did miles of hand-walking on a hard surface over the months of his rehab and he was eventually sound enough for turnout after around seven or eight months of stall rest.

[Weluvhaha]

My vet does not recommend using Voltaren instead of Surpass. I wanted to make sure I wasn’t wasting my money so I researched it a little bit and the two products do not have the same carrying/penetrating agents. I posted a scientific study about these substitutions. Different vets may have different views, some backed by a study and maybe some not. Chemistry/Pharmaceuticals is not always the strong point of every doctor, as I discovered with my children’s doctors.

[NancyM]

Tendon injuries tend to heal well, given time, given rest, and then given exercise. The exercise part is important, when to start it is a judgement call. Not too early (obviously), but not too late either. The movement of the horse, and the tendon, shows the tendon how much more healing it needs to do, to regain adequate strength. Stall rest, cold therapy, protection with a bandage or cast is the first part, but after a while, the protocol changes. When that might be depends on the situation… but don’t “baby” it forever. Eventually, you are going to turn this horse back out into a paddock, and he’s going to do what horses do. The tendon must be strong enough by that time to withstand that amount of stress.
The bandaging early on doesn’t “support” the tendon, it protects it, it holds medication in place. Use of a “cool cast”, alternating cooling with sweating, opening and constricting vessels helps, after the initial cold hosing or icing. Keeping the horse quiet enough that he doesn’t make it all worse in the early stages. But soon, he’s going to need exercise… walking at first. Straight lines, gentle turns. And eventually, paddock turn out. Tranquilizer helps for that first turn out into a paddock, and it’s best if you don’t watch… because it may frighten you to watch. Then don’t shut him into a stall again, in order to avoid that moment of celebration at release. Supply a nice quiet horse next door to keep him company and not encourage him to do too much too soon. Movement is key to healing… movement at the right time, not too soon, not too late. Because if healing completes without regaining enough strength, re-injury is likely. It’s walking a fine line when it’s done right.
When he’s looking sound, lots of trotting, under saddle with a light rider, gentle turns.
How long it takes is dependent on the extent of the original injury, obviously. But take heart… they can and do heal well. Deep flexor is worse than the superficial flexor, but sometimes both are involved with the injury.
Tom Ivors (Ivers???) “The Bowed Tendon Book” is interesting reading. It’s an old book now. It was considered “shocking” at the time it came out. But interesting. A previously bowed horse has won the Grand National steeplechase race.
Good luck.

[Peggy]

@Weluvhaha

One in chemistry

Probably general plus organic. Possibly a year of each. Maybe also a quarter or semester of biochemistry.

May or may not be relevant to off-label use of Voltaren. But an easily-verifiable mis-statement weakens an argument.

[Weluvhaha]

I stand corrected. They have sufficient chemistry. Therefore, they should not represent that surpass and Voltaren are exactly the same.

[Peggy]

Now that I’ve gone down the rabbit hole, which was rather fun.

I just learned that not all Voltaren is the same. Some is diclofenac sodium (Na), whereas others is diclofenac diethylamine (EtS2NH). Any Surpass I’ve seen has been only the Na version. According to this study done on humans the diethylamine version is more readily absorbed. Not that absorbed more necessarily equals more effective. Additionally, that study used a Na version that was 4+ times as concentrated as the Et2NH version.

The Voltaren vs Surpass study linked above (which I don’t have access to all of) was done using the diethylamine version of Voltaren and it doesn’t specify anything for Surpass (which may or may not be available in the diethylamine form). So possibly yet another variable.

Nerdy chem stuff: if you represent dichlofenac very simply as RCO2H, then the Na version is RCO2- Na+ whereas the amine version would presumably be RCO2- Et2NH2+. (with apologies for the lack of sub/super scripts which I know I’ve accomplished on here before).

Possibly useful vet stuff: vets have told me it’s OK to use Voltaren but warned that it’s not formulated for horse skin and hair and have recommended keeping the hair clipped very short where you want to apply it and rubbing it in a bit. YMMV.