founder risk with joint injections UPDATE post 14

[BrookdaleBay]

Back in May my 24 year old OTTB had flexions done for a front end lameness that had gone away the day before the appointment. The flexions revealed ouchyness in both hocks (nothing the vet was concerned about given his age) and his right stifle. He would occasionally loose his right hind when circling to the left. Vet said further treatment wouldn’t be necessary at that time, and I started doing hill work to help strengthen his hind end. Over the summer, stability in the stifle improved greatly.

Fast forward to end of August, September, weather got rainy and gross, and we couldn’t get out to the fields as much. He started loosing his leg again going to the left. This didn’t happen every ride, but it was happening often enough that I decided to get the vet back out. She saw him today and flexions revealed that his hocks had no change, but the stifle was worse by a degree. He’s already on Previcox and monthly Pentosin injections, so she recommended we inject to help keep him more comfortable.

Now to the part that has my overthinking mind racing. She took blood for an PPID test, given his age and despite him not having any Cushings symptoms. Its just a precaution. The injection would by hyaluronic acid and one other steroid - one with a higher chance of causing founder, and another with a lesser chance. She also suggested Pro-Stride or IRAP.

I’m lucky enough to board where I also work, and this vet has injected horses here thousands of times, including an older gelding with Cushings. No one has ever foundered from these injections. My gelding is 24, but doesn’t look or act his age, and in work 3 - 4 days a week. Aside from a suspensory strain a few years ago, he hasn’t even had an abscess! The founder seed has now been planted in my brain and keeps going to that place where he’s the unlucky one in the barn that does have a problem. For one stifle, injecting with HA would be around $400, Pro-Stride $700, and IRAP $1000 (definitely not going that route).

I know I’m over thinking at this point, but this horse is pretty much my child. All day I’ve been going back and forth between the HA injection, or springing for Pro-Stride. The vet also mentioned the PPID test can produce a false negative - that one sent my head spinning even more. Please, someone talk me off the ledge. My boy is healthy in every other way, his founder risk isn’t that great… right?

[AppaloosaDressage]

You’re not over thinking. Lost a horse from severe sinking in both hinds after steroid injection. It was bad. The horse was young, fit, and extremely talented. All horses on the farm that get injections get PRP or IRAP now. No risk of laminitis with this. Definitely an exponentially safer route and can be even more effective than traditional steroids that can cause laminitis.
Edit- I’ve never used pro stride but a mare on the farm that had stifle surgery was initially treated with PRP following the procedure, then was switched to financially more feasible IRAP last year. I remember the vet suggesting Pro Stride as another option but can’t remember if the owner opted to try it or stick with the known safer route, IRAP. I vaguely remember the vet telling her it was just as safe as PRP and IRAP. Definitely do some research and get second opinions to find out more about potential for laminitis with prostride. I want to say it was described as safe by our very trusted vet but can’t remember 100%

[Sansena]

If you[r’e at all concerned about steroid + cushings = founder, wait 3 weeks and have the TRH-stim. test performed for cushings.

No, you’re not over thinking at all. I’ve known vets who’ve injected joints/ tendons sheaths on horses who were, from outward appearance, NOT cushingoid. Except they foundered after the injections.

Once bitten twice shy, and definitely worth the due diligence in research. If other therapies are available to you, pursue them instead of anything involving steroids.

[stb]

I do know someone who had a horse founder after an injection. The horse was never sound again and eventually had to be put down as a result. It is a real risk.

[Laurierace]

Not an answer to your questions but have you thought about doing a course or estrone for his stifles first? No risk of laminitis and either works absolute miracles or does nothing so worth a try in my mind.

[Natalie]

You’re not overthinking. I went the IRAP route with my horse for his arthritic coffin and pastern joints for this very reason. He hasn’t shown signs of Cushings and his PPID test came back negative, but he’s 21 and radiographs show slight rotation in both front feet that didn’t improve with good trimming (radiographs taken almost one year apart). Vet wasn’t comfortable saying whether or not the rotation was a sign that he was having subclinical laminitic episodes, or just his anatomy (his front end is…a bit crooked, so it wouldn’t shock me at this point if that was the case). He’s managed well and both I and and my BO are diligent about watching his soundness, feeling for heat/pulse in feet, etc…but sometimes symptoms can apparently be so minimal that they’re pretty undetectable. She’d also never had a horse founder from traditional joint injections, but felt that he was more at risk than an “average” horse because of age and what the internal structure of his feet looked like.

I went with IRAP. It was very pricey, but had obvious effects. If I do every do a “top-up” of injections, however, I might go the ProStride route, since it is less expensive. And just to be clear–IRAP is actually initially a better value, since a single blood draw results in multiple tubes of serum (I believe we got 10 for my gelding, at a cost of around $900). However, the repeated injection protocol is what killed me because it drove the price up insanely–all of those farm call fees plus the actual fees to inject the joint added up really quickly. I have 2 vials left now, and once they’re gone, they’re gone. ProStride is done all in one visit, so the price works out to be significantly lower.

[Where_sMyWhite]

Count me in on you are not overthinking.

A very nice mare boarded in the stall next to my girl had a steroid injection with subsequent founder followed by euthanasia after her coffin bones went through the soles of her hoofs

I’d personally avoid steroids if at all possible.

[x-halt-salute]

You’re not overthinking this! Good on you for being careful with this kind of decision.

I second @Sansena’s recommendation to get A TRH stim test done, in general, just so you have maximal info for future care decisions. But that probably won’t help you make decisions right now, as there’s no established reference levels for that test during the autumn rise, so for accurate results you might have to wait until early spring.

FWIW, HA is not a corticosteroid. So the laminitis risk with a HA-based joint injection comes down to whether you also inject a steroid like triamcinolone (which carries risk of triggering laminitis in an otherwise susceptible horse) or methylprednisolone (which may be a bit less risky wrt laminitis, but has been shown to have negative impacts on joint cartilage over time, I seem to recall). The evidence for HA’s effectiveness is pretty limited, so injecting HA without a corticosteroid is likely to be disappointing. There’s no risk-free option if you go with a steroid injection, but FWIW I manage that risk in an aging horse with a history of laminitis by injecting only a single joint at a time and routinely testing ACTH (now planning to do TRH stim every spring as well, given age and history).

That said, have you done any imaging to determine that the problem is inflammation (as in osteoarthritis pain) and not patellar ligament laxity? If you’ve got rads of the stifle with signs of arthritic change, Prostride is absolutely something I’d be considering; if diagnostics point toward the latter, I’d start with a very specific rehab regimen and then consider the medical/surgical interventions available for UFP before settling on IA steroid injection.

[BrookdaleBay]

Thank you everyone for your replies and words of reassurance that I am in fact not over thinking.

Honestly, I’m terrified of him foundering. I talked to the BM the other day about this, and she said, to put things into perspective, this same vet has injected multiple horses at the barn, one of which is on Prascend for Cushings, as well as as a 35 year old, and none of them have foundered. Blood was pulled during Tuesday’s appointment for the ACTH test, but results wont be back until the end of the week.

I could go ahead and inject with steroid’s and everything will end up being fine, or he could be the unlucky one and something goes wrong. I would never forgive myself if that happened. All your replies here are making me lean towards Pro-Stride, but everything the BM is saying is making me think I am overthinking.

@Laurierace I’ve never heard of Estrone, what is it?

[Where_sMyWhite]

@BrookdaleBay

I could go ahead and inject with steroid’s and everything will end up being fine, or he could be the unlucky one and something goes wrong.

This, yes. You could inject with steroids and most likely, nothing will go wrong. You also could be one of the small percentage where something does go wrong. Even if the percentage is small, for you, it would be 100%.

Listen to your gut and do what it tells you… not what we tell you or what your BM tells you… what your gut tells you. Collect information (you have ), think and overthink as much as you like and need to then go with your gut. Often, it’s trying to help you with your decision.

Let us know what you end up doing

[x-halt-salute]

@BrookdaleBay

I’ve never heard of Estrone, what is it?

Estrone is a hormone similar to estrogen, and can be injected for UFP (sticky stifle). There’s still some debate about its exact action, but the theory is that it loosens a suite of ligaments (similar to hormones triggering ligament relaxation in childbirth) and thereby resolves the imbalance in ligament tension that causes stifles to stick.

For UFP corticosteroid injections can help make a horse more comfortable, especially as any abnormal joint function can create inflammation and discomfort in and of itself. But a lot of vets like to work through less invasive options that target the primary problem first first (fitness/PT, assessing shoeing, treating any other hind end lameness, then medical treatments like estrone, and finally more interventions like blistering and splitting). Your hill work was aimed at the fitness end of the spectrum.

If your horse has UFP, steroid injections might make him more comfortable, but you probably won’t 100% solve the problem until you address the mechanical dysfunction of the joint. Hence why it might be prudent to know whether the primary problem is something like a ligament issue or bony changes as you decide on treatment options. Your description of a horse “loosing his leg”, with improvement after hill work, sounds like ligaments are involved and might be the primary problem.

With the corticosteroid injections, like so many things in horses, there’s no way to boil it down to a black and white situation w.r.t. risk. There’s always some risk, even for a horse who’s never been laminitic, is in perfect fitness and health, and has no diagnostic indications of metabolic dysfunction. Just like every vaccination carries some small but non-zero risk of a catastrophic anaphylactic reaction, even for a horse who hasn’t had systemic reactions before. And every trailer trip carries some small but non-zero risk of an accident. You can assess risk and sometimes manage it, but for a lot of things we do to care for horses there is some risk. Only you can decide if the risk of laminitis outweighs the potential benefit of controlling inflammation in that stifle. A lot of horses who are at higher than average risk of laminitis (w.r.t. age, metabolic disease, prior history of laminitis) are routinely treated with IA corticosteroids without incident. However, there will never be a guarantee that your guy won’t be the unlucky one. Just like there’s no guarantee that routine vaccinations or hauling down the road won’t end in catastrophe.

[Laurierace]

@BrookdaleBay

Thank you everyone for your replies and words of reassurance that I am in fact not over thinking.

Honestly, I’m terrified of him foundering. I talked to the BM the other day about this, and she said, to put things into perspective, this same vet has injected multiple horses at the barn, one of which is on Prascend for Cushings, as well as as a 35 year old, and none of them have foundered. Blood was pulled during Tuesday’s appointment for the ACTH test, but results wont be back until the end of the week.

I could go ahead and inject with steroid’s and everything will end up being fine, or he could be the unlucky one and something goes wrong. I would never forgive myself if that happened. All your replies here are making me lean towards Pro-Stride, but everything the BM is saying is making me think I am overthinking.

@Laurierace I’ve never heard of Estrone, what is it?

Estrogen injections. Can use Estrone or ECP. Cheap and like I said, can work miracles. I try that first every single time with stifles.
http://steinbeckequine.com/pdf/DelayedpatellarreleaseMD.pdf

[Lieslot]

Coming 2 years ago I had to put my youngster down following a steroid injection to treat a minor splint on which he wasn’t even lame. One day I was still riding him, 2 days later he was gone. Foundered on both fronts within 24 hrs of injection, all 4 after 48 hours, there was no hope. This has been really traumatic for me.
I am very careful about steroid injections since.
As an aside, myself I had a biceps tendon steroid shot and got high IOP following that, I never had issues with IOP. Suddenly I am a glaucoma suspect and on daily meds.
Got to be careful with those steroids!

[BrookdaleBay]

Thank you again everyone for your replies and stories.

The vet called yesterday with the results of the blood tests, and he tested positive with a level of 16. She said 10 was the normal, and anything above 20 would warrant medication. She also said that this time of year brought on higher levels, too. We both agreed that injecting with steroids would be too risky, so I’ve decided to go with Pro-Stride. He has an appointment booked for next Wednesday morning.

In the mean time, https://www.facebook.com/jkoliff/videos/10156831676777153/ the beastie in question jumping for the first time since the summer.

[TWH_Girl]

Let us know how Pro Stride works. I’m about ready to pull the trigger myself to try it. Horse is 17 and we are testing for Cushings too.

[x-halt-salute]

@BrookdaleBay

Thank you again everyone for your replies and stories.

The vet called yesterday with the results of the blood tests, and he tested positive with a level of 16. She said 10 was the normal, and anything above 20 would warrant medication. She also said that this time of year brought on higher levels, too. We both agreed that injecting with steroids would be too risky, so I’ve decided to go with Pro-Stride. He has an appointment booked for next Wednesday morning.

What test was that? ACTH in pmol/L? If so, FWIW, the 10 pmol/L reference level is only valid outside of the seasonal rise. In autumn the reference level is much higher. Proceeding with caution sounds like a very reasonable thing to do, but if you really are worried about PPID you should follow up with TRH stim in the spring for a more accurate indicator.

Good luck with the Prostride! Hope it’s just the ticket.

[BrookdaleBay]

@x-halt-salute

What test was that? ACTH in pmol/L? If so, FWIW, the 10 pmol/L reference level is only valid outside of the seasonal rise. In autumn the reference level is much higher. Proceeding with caution sounds like a very reasonable thing to do, but if you really are worried about PPID you should follow up with TRH stim in the spring for a more accurate indicator.

Good luck with the Prostride! Hope it’s just the ticket.

The vet told me which test it was when she took blood, but my mind was swamped with so many other things that I completely forgot what she said. Retesting in the spring is a good idea, tough. Aside from bring a little fluffy, he doesn’t check off any other boxes for Cushings.

Thank you!