Please Help Me Decide! Proximal Suspensory Desmitis Update- Treatment Day! Post 22

[fanfayre]

Hi, this WILL be long, so please bear with me, as I value your collective wisdom:
19-year old gelding (ex)eventer, now transitioned to dressage (with a bit of low-jumping for cross-training), and aiming for 3rd level this summer.
I have read up all the threads I could find on PSL injuries, treatment and outcomes.

Presented December 19th with hitch in LH, treated with paddock turnout rest for 8 days, when not better added 1g bute x2 daily for 7 days, but then developed abscess in RF, so LH took a backseat. Just as abscess blew, 18-24" snow arrived for 7-10 days. Once snow melted and was able to reassess, hitch in LH still present. Took him to my vet the next day, Flexions returned no increase in lameness during lower leg and hock flexions, but increased when stifle flexions conducted. No x-rays or ultrasounds performed*. Sent home with instructions for strict stall rest, back on 1g x2 daily bute for 10 days, reassess in 14 days. If no better, then vet would refer me to lameness specialist associate (I feel I should mention I have a very good 33+ year relationship with my vet, who is board-certified- she did not shirk her duties [see below]).

• My vet did not do x-rays or u/s because she said IF stall rest + NSAID did not fix the issue she would be referring us to a specialist who would be redoing the same x-rays and u/s with far better equipment than she had, so why waste my money. I agreed.

After 3 days of stall rest (not a problem- he likes his stall!), another horse rehabbing a different injury (and sadly the one my guy is completely attached to- I joke he’s attached at the brain) left the barn for her exercise, and my guy lost it. Kicked the stall boards, completely lathered, screamed himself hoarse. I emailed my vet, who thought he was having an issue with stall rest, but told me to contact the specialist. We developed a coping strategy to get through the next 10 days during the 40 minute separation until our specialist appointment.

Which brings us to now. The specialist was very thorough, redid our initial investigation, same results to flexions, so we started the rads and u/s of the stifle, which showed clean for his age and level of lifetime activity, so that was good, I guess, but it left us wondering what the problem really was.
The upshot is he has an injury to his upper proximal suspensory ligament . No u/s was performed that day because too mush fluid for blocking had been introduced.

Here;s where I need your help:
Which treatment option do I choose-

1. PRP (or other biologic) + SWT + rehab (how long?) Performed by the specialist who diagnosed PSL
2. neurectomy/fasciotomy + rehab? (again, how long?) Performed by 1 of 2 other specialists I would have to approach.

Keep in mind he’s 19. I have been told either of these options would very likely return him to our level of training/competition IF rehab was successful following either treatment. Both options appear to be within a few hundred $ of each other, fully out-of-pocket.
I suppose, even if he returned to trail-riding sound, it’s better than he is now…

There is, of course the 3rd option: retire him right now, but as sore as he is, and with the low success rate of Dr, Green solving this problem, euth is the more likely 4th option, but one I will consider so as not to make him suffer.

Thanks so much in advance!

[2tempe]

@fanfayre

neurectomy/fasciotomy

Management of hindlimb proximal suspensory desmopathy by neurectomy of the...

I dont know much about either of your options in this situation, but this article may help. They talk about the impact on success of some conformational things and other possible contributors to lameness. Somewhere I read the rehab is around 8 months for the surgery, but dont hold me to that.

[fanfayre]

Thank you.
Yes, I have read that; I have done a lot of reading in the last 48 hours

[fanfayre]

A new treatment possibility?

I also read this, and may see if the specialist has any knowledge of it/is willing to try.
Has anyone heard of or tried this/knows someone who successfully used this method.

[Libby2563]

@fanfayre

The specialist was very thorough, redid our initial investigation, same results to flexions, so we started the rads and u/s of the stifle, which showed clean for his age and level of lifetime activity, so that was good, I guess, but it left us wondering what the problem really was.
The upshot is he has an injury to his upper proximal suspensory ligament . No u/s was performed that day because too mush fluid for blocking had been introduced.

I would not make the decision without an ultrasound. I was put in that position once by a vet I really trusted, who diagnosed PSD based on his experience, the clinical exam, and blocking (with no ultrasound because of the blocks, same as in your situation). Long story short I did do the neurectomy but it didn’t help and when ultrasounds were finally done much later, the suspensory branches had more pathology than the proximal suspensories. Your first two options are both expensive so for me, one more vet trip for a definitive diagnosis would be very worthwhile.

[fanfayre]

Thank you-I remember reading your saga and resulting heartbreak.

The specialist did say that she wouldn’t be doing any treatment without an u/s beforehand, so I’m sure if I request an u/s of the full suspensory on BOTH legs she would comply, because, hey, it’s my $.

[TequilaMockingbird]

My mare was diagnosed with it in both hind legs when she was 8YO at Texas A&M via ultrasound. I did approximately 6 months of stall rest for the lesions to completely heal, which was also confirmed by ultrasound. Then I had the neurectomy surgery done. She was on stall rest for 2 months to recover from the surgery and then very slowly brought back in to work. This was 6 years ago. Full recovery time was about 18 months.

I still have a lot of physio work done on her to keep her comfortable in her work. But I haven’t seen any issues related to her suspensories since the surgery. She is turning 15 later this year. I’m really picky about the footing I will ride her on as I believe the arena footing at a previous barn caused a lot of her issues.

I think surgery is the best option in most cases. But I honestly doubt you will ever get him back to his current condition. At 19YO, it’s going to be hard to get back that muscle back once it’s gone.

First priority is to get him comfortable. When my horse was on stall rest for 6 months, I was told a really small paddock (not enough space to actually run or trot) would also work. I tried standard stall rest for a couple weeks and saw how miserable she was. I moved her to a barn that I could get a stall with a small run attached so she wasn’t bored or feeling alone. It made her stall rest period much easier for her.

[fanfayre]

@TequilaMockingbird

At 19YO, it’s going to be hard to get back that muscle back once it’s gone.

THAT is another of my concerns. He looks great right now- fit and muscled even though he’s not been worked in 8 weeks now. However, a year ago he looked awful too- no muscle, no topline, and he came back to peak fitness quite well quite quickly, so…

He does like his stall, but once his partner in stall rest is given parole, something like you set up for your horse is going to be needed because he won’t be able to handle solitary (understandably- he’s just herd animal after all).

[Feathered_Feet]

I agree with Libby - you need to see how much inflammation there is and what the fibers look like to understand the severity of the injury, and thus what the appropriate course of action would be.

Another data point to consider, though - how long do you think he’s had PSD? In my case, my horse was imperceptibly lame, but just not right for an extended period of time. When we finally identified the PSD as an issue, looking back it had been quite chronic (maybe a year, or so?) so I opted for the N&F as I was concerned about the chronic inflammation and resulting compartment syndrome not going away once the inflammation was resolved. I.e., just because you resolve the inflammation, the nerves may have chronic damage themselves. In my case, we did N&F, then PRP when the 6 week recheck was only “meh”, then she healed beautifully. We did only a few weeks stall rest post-surgery, then quiet, sedated turnout, and daily handwalking at a good march on trails (leading up to 50 or so minutes handwalking over the course of several months). So while mine wasn’t FEI fit as she was before, she wasn’t unfit and legging-up was pretty straightforward.

But you really need an ultrasound from your specialist. The fibers can be a hot mess, or just your run of the mill inflamed. (Fibers on mine were pretty good, but the inflammation was bad.)

[quietann]

If you’ve been searching threads, you’ve probably found the one from some years ago in Eventing… I was one of the contributors there as my older mare had this surgery and PRP back in 2010 when she was 12. Post-rehab, which took about a year, she came back at 95% of her former abilities, and we did some dressage and a lot of casual trail riding. She was sound with maintenance - has been on Equioxx almost continuously for 10 years, required joint injections pretty frequently, etc. In 2022 I retired her due to arthritis and mild heaves. She’s doing quite well though showing her age a bit at almost 26.

One thing I learned is that every horse is different, but horses with the issue can get quite sore in the SI joints, too. Eight months in, her rehab stalled out and the vet found her SI area to be so sore that he could nearly make her sit down by pressing on it. She got SI injections then, which helped a lot, and had them about once a year after that.

[fordtraktor]

I wouldn’t make any decisions without an US. See where you are first.

[IPEsq]

Given horse’s history, and depending on what the ultrasound looks like, I’d be inclined to try biologics first and see if you can get him on a controlled exercise program to help retain as much core fitness as you can. Back and SI issues can definitely be a problem with rehab especially in an older horse. Also check hind foot angles to make sure that’s all good.

When his buddy leaves to be worked, would he be ok to go out for a hand walk and groom or something?

[fanfayre]

Thank you all so much for your very helpful input!

@Feathered_Feet: I’m pretty sure it’s a new injury, about a week before Christmas. One day he was striding out, the next day was our lesson, and within 10 strides my instructor, who’s known him ALL his life too, called out that he wasn’t right. We had been having weekly lessons for 11.5 months at that point so she had a pretty good idea of his regular movement.

@quietann: Yes, I read your thread! I will definitely keep an eye on his SI.

@fordtraktor: U/S, probably on both legs, and along the full ligament, will be on order, no matter how crazy the specialist thinks I am.

@IPEsq: yes, I have been trying to coordinate barn time with my sister’s, so I can remove him from the other horse before she leaves the barn. He then can go back in and get a treat of some alfalfa hay or another distraction, and he’s mostly fine with that. However, often my sister’s schedule and mine doesn’t mesh, as I may be working and not in the vicinity of the barn or even at home. When I can’t get there, she brings in my other crocked horse for company and gives them both a snack. We also have some otc ‘happy juice’ to give him if he appears to be on the tipping point of the anxiety taking over even with Vida (my mare[avatar]) as babysitter.
He has a fabulous farrier (the best on the island-I’m very lucky I’m his client and will do anything he says no matter how expensive he is) but will have the angles checked AND have the suspensory shoes put on when he gets reset.

The biggest thing is I only have 1 shot at this. As it is, I will be borrowing the funds from my mother’s estate to pay for whatever treatment method I choose (and at this point I’m leaning heavily towards PRP), so I need to choose the method with the highest likelihood of success. If PRP doesn’t work surgery won’t be performed.
(Now with me admitting that I won’t be surprised if all the future responses tell me I’m an irresponsible owner and I should get out of horses all together). Believe me, I’ve told myself that many times

[Feathered_Feet]

@fanfayre

@Feathered_Feet: I’m pretty sure it’s a new injury, about a week before Christmas. One day he was striding out, the next day was our lesson, and within 10 strides my instructor, who’s known him ALL his life too, called out that he wasn’t right. We had been having weekly lessons for 11.5 months at that point so she had a pretty good idea of his regular movement.

Oh! In that case, I would say that there is almost certainly no reason to do surgery. Just do PRP, shockwave, and rest. It’s probably also not desmitis, then - it’s probably just a tear or strain, which is typically more straighforward Keep us posted on what you find on ultrasound. Good luck!

edit: If the tear is large, surgery could be indicated to fix that. But it would not be N&F surgery But the non-surgery approach can be very effective, even for large tears.

[fanfayre]

Oh, thank you!

[MissusS]

Late April/early May last year my mare injured her hind suspensory. We ultrasounded and found right hind medial suspensory branch desmitis (new injury) and right hind proximal suspensory branch desmitis, mild (possibly older injury that did not heal properly).

We went with Renovo and 3 shockwave treatments. We ultrasounded every 4 weeks for the first 6 or 7 months I think, and at first she was not showing as much improvement as the vet would have liked… it was probably 5 months post injury before we really saw much improvement in the fibres. We have moved to rechecks with ultrasounds every 6 weeks and are 9 months post injury.

Today was the first day we added a few (intentional) canter steps under saddle. We are up to 20 mins walk, 10 minutes trot. Based on the rehab program by the time we have our next recheck in 6 weeks, assuming we continue to progress well, we will be up to 2 minutes of canter. We are proceeding VERY slowly and patiently through the rehab.

Would we have progressed even more slowly if we hadn’t done the injections/shockwave? I honestly don’t know, but I’m glad I did it to give as much chance of success as possible. I would do it again, regardless of her age, if a similar situation came up. I think I’d be a lot more hesitant to do surgery, though.

Good luck with your decision, it’s a really crappy thing to have to work through.

[TWH_Girl]

@fanfayre

The biggest thing is I only have 1 shot at this. As it is, I will be borrowing the funds from my mother’s estate to pay for whatever treatment method I choose (and at this point I’m leaning heavily towards PRP), so I need to choose the method with the highest likelihood of success. If PRP doesn’t work surgery won’t be performed.
(Now with me admitting that I won’t be surprised if all the future responses tell me I’m an irresponsible owner and I should get out of horses all together). Believe me, I’ve told myself that many times

No one is going to say that. These are all tough decisions that many of us stew over and there is no right or wrong answer. If you’re going to do a biologic, I’d do Prostride because it’s PRP and IRAP combined. It’s a good product.
If it’s a one shot deal, I think I would do the surgery though. This is fortunately one of the many conditions I don’t know a lot about specifically but I have used prostride and also used shockwave and agonized over choices for my boys over the years so that part I understand.

[fanfayre]

Thanks.
I will see if the specialist has the ability to do Pro-stride, or if she’s only able to do PRP.

Edit; I finally looked up her website, and yes, she DOES advertise she offers Pro-Stride, so, yay, finally a glimmer of light!

[ndirish07]

I’ve commented on PSD several times has I’ve done it twice on the same horse, different legs. Both times I’ve done the fasciotomy, no neurectomy as the horse wasn’t a candidate for that part. RH was first. He had a core lesion. We did fasciotomy, PRP during surgery. Then did 5 rounds of shockwave and a long session of a class IV laser. It healed well that there wasn’t any scar tissue and horse was sound and back to work for a couple years. Last year, horse did his LH and I learned no, Hagard doesn’t do BOGOs. He was in Florida for training when it happened because horses’ timing is poetic. No lesion in the LH just inflammation. Tried conservative treatment with Prostride and shockwave and he wasn’t sound enough for the amount of time so he came back home and had fasciotomy on the LH in April 2023. I did a Class IV laser on that LH and that was when the last of the inflammation left and he was perfectly sound. We’re still technically rehabbing only because it’s been freezing cold and I haven’t been riding and haven’t taken him for the last vet check but he’s sound. Very sound. Hopefully, the LH is like the RH and he doesn’t ever take another lame step on it again.

[TWH_Girl]

That’s good news on the vet offering Prostride! Something like the cold laser or even red light therapy as a follow up might help afterwards too.