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Suspensory Injury Rehab, Prognosis, and Help?

My mare (12 year old Welsh/Quarter cross) sustained a lateral branch suspensory injury. We are going on week 6 of treatment and there have been no improvements. Initially, she was grade 3/5 lame with slight swelling and heat now she’s still 3/5-4/5 lame with prominent swelling and heat. For treatments, I have been stable bandaging her 12 hours on 12 off, cold hosing daily in the evenings, icing daily in mornings, applying epsom salt poultice (green jelly kind) overnight, and strict stall rest. All this is done as per my vet.

Initially, she was getting half-dose bute (sensitive tummy) daily but that was too much for her to handle and she started to show ulcer symptoms. Should I be seeing improvement? Any other ideas on treatment? I’m a student and thus don’t have a lot of money for ESWT or PRP or such.

What experiences have you had with branch suspensory injuries? Prognosis for return to competition/riding? How often do these injuries become chronic?

I would get a second opinion. That is not a routine I would follow.

What kind of routine would you recommend?

What type of sesamoid involvement (any avulsions) and on which leg? Tear %?

Suspensory injuries are very varied in their prognosis. It depends on the type of injury and which limb, if any avulsions/sesamoid fractures are involved, the horse and how it handles its newly restrictive lifestyle (is she a good patient?), how well the initial healing process goes, and whether or not the horse has access to major medical treatment/care as well as quality farrier care… many front suspensories are causes by incorrect angles up front IME.

Inflammation and heat is not uncommon in branch tears. You’re only at a month. These things take a long time - as in a year to two years long. However long it takes to “heal”, multiply that for the “rehab” - so if it takes 2 months to heal, consider you will be looking at minimum 4 months for careful rehabilitation. Take it slow.

If you are looking to manage pain look into previcox and/or devil’s claw & yucca to help with inflammation. You could consider Platinum Performance CJ as well, I put any horse on it any time there is a soft tissue injury… it really helps them recover, reconstruct, and keep the inflammation down. You can also look into SmartFlex Rehab. Also consider drugs for the rehab - ace or resperine if she is not a good patient.

Unfortunately if you are a student and you can’t afford the PRP/shockwave, that is okay but you are looking at “controlled conservative management” over “medical/technological management”. There isn’t anything wrong about that, I myself have been in the same position.

Personally I would not ice, I don’t think it’s conclusive to healing. JMHO. I would Surpass on days that she is very inflamed and look into a joint/anti-flam supplement like mentioned above. Wrap 12hrs on/off as you are doing.

So much of the prognosis depends on how good of a patient the horse is… really… It can be so heartbreaking but we can’t explain to them “you need to be quiet for 10 months in a stall” - they just don’t get it – and they can and do hurt themselves in stalls if they are not feeling like their lives are enriched or entertaining.

How is she handling her new lifestyle? Is she quiet or is she very active? Some horses are much better (and in turn, give themselves a much better prognosis) if they are provided with an outlet - sometimes it’s as simple as making a 4x4 "outdoor stall’… sometimes you have to just turn them out and see what Dr Green does.

Without knowing more I would say that we generally only wrap the first few weeks/month, and after that it depends on the injury’s severity. Usually we see handwalking by six weeks.

FWIW, my late TB sustained a RF suspensory injury, it was a full tear. We tried the traditional controlled management, this was before PRP/shockwave and he just about crawled out of his skin within a few days… He was so unhandleable that it was no question that he was doing more damage to his injury being in a stall than he was being out. We turned him out to 24/7 pasture and he had about 18 months completely off from work… and then about 6 months of VERY regimented and careful work with no cantering… but he enjoyed a long (12+ years) and successful career as a low level eventer after the injury. With him I firmly believe that because he was quiet on T/O and was a sensible horse, he was able to recondition the limb and it never, ever bothered him again. He didn’t have the scope for much over Training eventing but he was able to train and work hard as Pony Club horse & eventing partner for years.

I forgot to mention that it’s a left hind tear with core lesion I can’t remember the % but I know it was more severe than the vet had anticipated. There wasn’t any sesamoid involvement and it is suspected she injured it while out in the pasture being silly.

She is a hot horse and paces quite a bit. We have another horse stalled next to her which seems to help but she flips if the horse is taken out at all and I can’t turn out because she’s wild in the pasture, unfortunately.

I’m just at a loss with what to do and so worried about her because she’s my baby and my first horse (I’ve owned her for 5 years now). She just seems so miserable all the time.

I would seriously, seriously look into something hard like Reserpine… she needs to be quiet for a lesion and hind suspensories.

Hinds do not have the same favorable outcome that fronts do, too much is involved and frankly there is not often a return to previous level of work. The best I think you can do for her is make sure she is very, very quiet… and feed her very well - they need a lot of calories and nutrition to recover from something that severe.

IMHO pacing in a stall can be very detrimental to rehabilitation. I really would see if it’s possible you can construct an outside “stall” where they are out and moving but not enough room to gallop/spin. I’ve done a 20x40 with very good outcomes. Consider a goat or pony friend if she needs one.

With hind lesions the most important thing is the initial healing… and if there are any complications while healing the prognosis gets very poor.

For the hot phase of a soft tissue injury, I bandage 24/7, with once or twice daily bandage changes. I think the cold hosing or icing is fine, for 15-20 minutes at a time. With a hind suspensory branch injury with so much lameness and heat, have you ever done a medical bandage? Meaning usually a sweat wrap with plenty of vet wrap and elastikon? To get on the road to healing, you’ve got to get a handle on that swelling and heat somehow.

I don’t think you are going to want to spend the $$ on Platinum CJ, but you could get some anti-inflammatory effect from MSM for less money. I think if you have the money to spend on Platinum CJ, you have the money to spend on PRP, and that gets injected right at the area of injury. I like Platinum’s Osteon product for a lot of soft tissue or bone issues, and it’s much less expensive. It is kind of a lot of powder, though, so if you have cut back on her food, it may be hard to get her to eat it.

I had some success with Prozac for the stall rest craziness where the horse couldn’t bring himself back down once he got worked up about something. A lot less risk of side effects than reserpine.

I had a horse with front torn suspensory. It has been 3 years and on and off times of not being lame but mostly lame. He has been kept in small area in pasture with other horses but no improvement. I’m not sure to the degree it is because I didn’t have him when it happened but have had him vetted while here we did not do mri as it is way out of my price range. We tried red light therapy and keeping him locked up but the second he gets loose he takes off or spins and it starts over. You are looking at way more than 6 weeks to see improvement. The horse needs to be confined to area so that they cannot run and if you take her out she needs to be on a lead line for a long time I would suggest planning on a slow steady 6 months of nothing but walks on leadline on level ground and not far if at all but to just take them out for some interaction or grass time. I don’t foresee any major change for my boy, its been a long time with reoccuring insult to his injury. I hope that you are able to get her pain under control and that you figure out a way to calm her so she isn’t reinjuring herself repeatedly.

The stall is an open one where she can see everything but she still paces. My vet (I think I need to look into a different one) said that the only think I could do to help her chill is to provide free choice hay to munch on.

She’s currently on Nutrena SafeChoice Perform and Balance.

Ask about a reverse shoe and a normal one for balance. (The heel is covered and the toe is open)

The SafeChoice Perform is high NSC. You may want to just have her on the Balance for less starch during this time and hay.

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Getting her quiet is critical. I tranq as much as necessary to curb any excess energy. With most of them, you can reduce the tranq over time as they accept their new lot in life.

I also wrap 24/7 until the heat is gone and the swelling is gone or nearly so, then wean off. My vet starts controlled exercise early - usually 5 minutes of hand walking on hard ground twice per day (with extra tranq if necessary to avoid blow ups).

I’d also suggest a Nibble Net to slow down her hay consumption, while still having it in front of her 24/7.

Do you mean a first aid wrap with like rolled cotton and vetwrap?

She does have a haychix net filled 24/7 and I’ve decreased the amount of Perform she eats (to about a cup because it seems to really help her tummy).

My vet told me I should see SOME improvement in a month but obviously that hasn’t happened.

Yes, I mean with rolled cotton. But some vets use a fair amount of elastikon as well for more support than vetwrap or a standing bandage. And with a sweat mixture, that can draw out a lot of the inflammation. I’ve seen it done for both tendon and suspensory injuries by a few vets. It’s not uncommon for soft tissue injuries that are acute like this to get worse before they get better. But during this hot phase, doing whatever you can to control the inflammation is important.

Maybe sweat it for a couple of days (these bandages don’t need as frequent changes unless it gets loose) and then go with wrapping 24/7 for a bit, with doing your icing at times of bandage changes.

I think there’s mixed feelings about special shoeing, but a reverse shoe or eggbar might help. At the least, I don’t think anyone wedges anymore because you want elastic healing. Iconoclast makes an orthopedic sport boot that has firmer support under the suspensory apparatus that can be used during early stages of walking rehab to help prevent hyperextension, but you aren’t there yet.

I am wary of using a sweating mixture on her because she has incredibly sensitive skin (Ice Tight poultice was even too much for her skin).

My gelding tore his LF suspensory May 30th. His was a small lateral branch tear midway between the bifurcation and insertion. He was on Reserpine for several weeks of his total stall rest, as he was prone to piaffing during his hand walks. As a side note, much of his rehab walking was done under saddle, as he was much less prone to taking off with me astride than on the ground! This was his protocol:

June 1: Ultrasound to diagnose. Grade 3/5 lameness.
June 1-14: Complete stall rest with hand grazing BID, ice boots for 20 minutes BID, wrapping 24/7 and applying Surpass SID
June 14: Denoix aluminum suspensory branch support shoe put on
June 15: Shockwave Session #1/3
June 15-26: Began hand walking for 10 minutes per day, adding 2 minutes of walk every day until at 30 minutes. Still on stall rest, wrapping and icing BID.
June 26: Shockwave session #2/3, repeat Ultrasound showed mild improvement, but still jogged 2/5 lame.
June 27-July 10: 30 minutes walk daily. Still on stall rest, wrapping and icing BID.
July 10: Shockwave Session #3/3
July 11-Aug 4: Started adding trot to 30 minutes walk at a rate of 1 additional minute per day. Completely sound under saddle at a trot.
July 18: Hock injections, 3 days off
Aug 4: First day of return to normal turnout schedule
Aug 5-13: Continue adding trot until at 30 minutes walk and 30 minutes trot daily
Aug 14-Sep 3: Start adding canter at a rate of 1 additional minute per day, subtracting one minute of trot for each minute of canter added, such that total daily ride time is 60 minutes. (So Aug 14=30W/29T/1C, and Sep 3=30W/15T/15C.
Sep 4: Returned to untimed dressage sessions.

Horse is now back to 3rd/4th level work and is sound as can be. He is still in a Denoix aluminum suspensory branch support shoe, which will likely be removed at his reset in 5 weeks. We have instructions not to jump for 6 more months or so, and we’ve switched from DSBs to polo wraps for everyday riding.

This is the suspensory shoe he is in: http://www.grandcircuitinc.com/products/denoix-suspensory-branch-front. Denoix makes a similar hind shoe.

Sorry to hear your rehab isn’t going as planned. Hind suspensories can be very difficult to rehabilitate, but posting to show you that there is hope for lateral branch lesions, though the recovery time will vary greatly. Surpass may be helpful for local control of the pain and inflammation, and Reserpine is excellent for quieting his brain during the stall rest period. Wedgewood can compound it fairly inexpensively, but you may need to add BioSponge to help with the resulting diarrhea. Good luck!!

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I had a filly that had a LF suspensory injury with an avulsion. It occurred in early Feb and she was back in work by August. She had three rounds of prolotherapy (this was before PRP was common). What I paid for prolo was much less than PRP costs. I’m not sure if that is still the case but may be worth looking into. Getting a good farrier involved is also key.

How much weight is she bearing on the limb? Be sure to pay attention to her other hind limb as the longer she has lameness, the greater the risk of contra lateral limb laminitis.

I found surpass to be superior pain control for my mare to equioxx. That may not always be the case but for her it was and that may be worth a try. I’ve read that there is less systemic uptake of surpass (other COTHers may have better info on that) and if that is the case then it may be a better alternative for her ulcer issues. Either way, I would recommend at least using a preventative dose of UlcerGard. Full treatment if you confirm ulcers and equishure if she is prone to hindgut ulcers.

Keeping her her quiet is going to help. I would discuss options with a vet and get something going to sedate her asap. If your vet is not up to date on suspensory injury rehab, it may be worth a second opinion. Dex has 4 vets that communicate about various things that are ongoing with him and they have all been happy to consult and give feed back. I remain thankful that my vets will defer to each other’s area of expertise.

This is is a tough injury to deal with. You have my sympathy and hopes for a quick improvement.

I’m sure this won’t be helpful but might give you a tiny bit of hope. My horse had a right front proximal avulsion fracture involving the suspensory. Thankfully not much damage to the suspensory but he had 3 decent chips off the bottom of the knee. The vet was not hopeful for a good outcome. I was feeling fed up because it was the millionth thing to go wrong with him so I just asked the vet if we needed to euthanize and when she said not yet, I told her I was not going to lock him in a stall again. So he spent 2 moths in a smallish turnout pen and then got sent away with shoes pulled for 10 mths of pasture rest. No invasive or expensive treatment at all. I brought him home this past June - he jogged lame at the vet. Seemed to block at the suspensory (mostly because me and the vet were feeling fed up that day and just blocked the suspensory). So I took him home with plans to let him hang out in the pasture until Christmas and then look again. A week later I texted the vet to see if it would be ok for me to walk him under saddle. He walked for 2 mths and then looked sound on the lunge. So I added a tiny bit of trot. At this point he is walking over pretty rugged trails without a problem. 3 1/2 months later he is walk, trot, canter on trails. Had a minor episode of lameness that turned out to be sore feet so he got shod. The vet who looked at him thought the suspensory was good and healed and should cause no further problems. I can’t believe how well he is doing. I hope you have the same kind of luck.

turn her out with a lazy gelding in a large pasture (4-5 acre)
keep her stalled and on a tranquilizer (probably the reserpine)
both for 4 months as per new vet’s recommendedation.

Are you not hand walking her at all? I would try the pasture but not until until she has had a few weeks of hand walking 2-3 times a day.

My gelding had a moderate tear to a front branch with partial detachment from the sesamoid. He was walking 20 minutes twice a day from the beginning, then up to an hour per day. He also got turnout in a tiny portable paddock. He got three rounds of shockwave initially, followed by stem cell therapy. He began working under saddle around seven months in. Two years later it is completely healed, such that there is zero evidence on ultrasound that any injury ever occurred.