Ultrasound Update - Cue Despair

Prair has been getting more than her fair share of attention from her arsenal of vets recently.  Aside from the check up on her Left Hind, our GP has been out to try and investigate her chronic diarrhea which has made a angry resurgence.

I'll start with the check up on her left hind, since that's most of the drama. 

We started by lunging Prair on a small circle, where, even with a heavy martini in her veins, she was still exhibiting Dragon-like-symptoms.  But once a bit settled, she looked great.

Both directions.

No limp, no shuffle, no quick step.  Sound.

So we flexed.

And that's where the wheels fell off the wagon. 

Her left fetlock flexion is still really positive.  She shows obvious discomfort at the flexion being held and the first two steps off the line looked nearly as bad as I remember eight and a half weeks ago when this adventure started. 

I almost canceled the Ultrasound since we knew it wasn't going to show brilliant progress, but I was too curious and too interested to delay the opportunity to get more information.

The (little bit) of good news is that general inflammation in the area is down.  There is still some edema around the suspensory, but less than there was 8 weeks ago.  The medial branch of the suspensory still shows a small area of disruption, but appears to be making (some) progress.  This would be great news f the DDFT was following suit, but the DDFT looks exactly the same as the images we saved from the previous ultrasound.

There is s slight line showing on the DDFT, which is likely a small split in the tendon.  We can't confirm exactly what or where without an MRI, but I'm still holding off on that procedure since confirming it's a split doesn't change any treatment plans. 

Essentially, the vet took one look and asked for two more months of stall rest followed by another ultrasound.  A pattern we would keep repeating until we see either improvement in healing or scar tissue form. 

crap

Obviously not what I wanted to hear.  I am extremely skeptical of miraculous healing when there hasn't been much indication of progress in the initial two months - especially when the structures received PRP and shockwave to invite progress with limited results...

So. 

There we are.  I spent the long drive home from the barn being fatalistic and trying to think about my (reasonable) options.  One thing I am fairly certain of is that if we can get meaningful healing, and Prair comes back sound on that limb, I don't think it's fair to ask her to jump (however small) again as her primary job.  Attempting to rehab her as a solid, exceptional Dressage mount for an Ammy seems more responsible. 

At this point (as in today, thought I'm sure I'll waffle on this), I still really want to jump, so if Dressage-Ammy-Mount was an option, I'd likely be looking for a home I trusted for the big mare.

Of course I have to consider the possibility that she won't be serviceably sound and think about what that means too. 

She's pretty, she has great bloodlines and two (stunning) babies on the ground, so we know she has value as a broodmare as well... it just seems too soon for her to become a professional mama.

Anyway, obviously for the time being some patience is probably what I need the most - but it's hard not to let my mind race a year down the road and wonder if I should try to move her now to a less expensive facility where she can enjoy her (extended) rest in a slightly more affordable fashion. 

Though my immediate reaction to that thought is concern over moving a horse that I want keen eyeballs on to a facility where the service level might be lower and the staff won't be familiar with her.... Not necessarily a great tradeoff, especially for peace of mind.

Lots of thinking to do, and thankfully a sunny, beautiful weekend coming up so I can wallow in my Mare Despair, probably with wine in hand

Ugh.

All the Toys Now...

Went down to assist in the Mare's spa day with the vet, which really only entailed me holding my checkbook firmly and watching the dolla dolla bills fly away home. 

Hairy. Eyeball.

Prair received her final shockwave session and a PRP injection into the medial branch of the suspensory.  Right now we are operating under the hypothesis that the Suspensory is the "primary" injury, and that the strain on the superficial and the DDFT are ancillary to that. 

It's never a good day at the vet when you see them unpack every single machine from their truck. 

ultrasound, check.

centrifuge, check.

shockwave, check.

I suppose we left the digital xray safely packed away, but still - I had to take a gulp as I watched all the Pelican boxes get stacked up and unpacked...

I had never watch PRP done before, so I was semi fascinated with the actual process of separating the blood sample (60cc of it.. holy smokes that's a big syringe) into red blood cells, platelet poor plasma (PPP) and Platelet Rich Plasma (PRP).  After processing, you come away with about 2cc of PRP, a lot of PPP and a lot of RBC.  Fascinating.

The horses were less fascinated and in fact were less than thrilled with something that smelled like blood and sounded like a spaceship. (I don't really blame them)

The PRP injection is guided by ultrasound, so we got a partial peek at what things look like, although since a different probe is used, it's not as useful (or comparable) an image relative to what we saw before.

It was pretty easy to see where the disruption of the suspensory is - in fact it shows up on the screen as a cloudy dark spot.  The sort of "void" that makes my stomach totally clench up and freak out - though my vet assured me the dark is an interruption but not a lack of tissue.  She still doesn't feel there is a full tear or even "lesion." So I tried to comfort myself with that interpretation.

Since we're only three weeks out from diagnosis we wouldn't expect to see much in the way of healing yet, but there was still a part of me that was hoping for some sort of miraculous progress.  Instead we'll wait 5 more weeks before we do a full comparison ultrasound.

As such, we're back to our regularly scheduled programming... turnout in the morning, wraps in the afternoon, stall and naked legs at night.

wash, rinse, repeat.

Puffy.

We've settled into a good stall rest routine for the mare.  We learned a lot last time around and I think everyone is happier for it.  For one thing, I'm still riding.  There's a.... sensitive gelding who I'm able to lesson on a couple times a week.  So that helps me.  a lot. 

The mare is still behaving, so she's getting several hours of turnout each day, which has to be good for her.  It's like she knows she has to be on good behavior because she is cool as a cucumber, more so than she normally is.  I've pulled her hind shoes, and her fronts have swapped back to regular shoes (not bar) while she's out of work.  In an ideal world I would have liked to pull her fronts too, but I don't trust the quality of her hoof right now and I don't want to add any soreness to the mix while we're stabilizing. 

More grazing - now with wraps

The only setback has been that the mare's legs got very, very puffy on Monday.  Like, stovepipes to her hocks puffy.

Prair has a pretty regimented wrap schedule right now.  She's naked at night, and while she gets turned out in the morning.  Then, when she comes in she gets ice boots, which has been followed by standing wraps with a poultice. 

I learned yesterday when I was there (and poking at the very puffy legs) that she was also getting poulticed (but not wrapped) overnight to help keep things tight.  I think that perhaps her skin got irritated?  I have no other explanation for equal swelling in both legs (swelling that was present when her wraps were removed).  I was worried that so much fill had reached her hocks.. and was showing no sign of leaving, even after bute, tri-dex (in case it was allergic) and handwalking.  But the mare was quite, eating, and comfy with no signs of distress or concern.  I left her in plain standing wraps with assurances that I would be called if things looked worse.

Today, Prair's right leg is normal (whew) but her left hind is still holding some fill, with a little up in her hock.  I'll be back at the barn tomorrow, and if things still aren't normalizing, I'll have the vet out.  The vet is already planning to be out on Monday for shockwave and PRP, so I'd like to avoid adding another trip, but I don't want to mess around with prolonged swelling, especially if it's creeping up the limb... (ugh).

As for me, the catch rides are good.  Mr. Gelding Man is the opposite of Prair in pretty much all possible ways.  He's compact and quick, light in the bridle and loves jumping but is a reluctant student on the flat.  He's rock solid where Prair isn't, and he's hard where Prair is easy for me.  So basically I'm exhausted after every ride and able to work on some of my own mental hang ups.  I'm a very confident rider on the flat and don't mind a horse that bucks/kicks/takes work to move off my leg or collect.  Mr. Gelding Man does all of those things, (where Prair is a willing partner on the flat) so it's good work for me.  Over fences, Mr. Gelding Man is supremely confident and very comfortable from any distance.  I can miss by a mile and he is just as happy as he would be with a perfect ride.  Prair is decidedly not happy when I miss by a mile (or an inch), so it's a good opportunity for me to stop overriding and get comfortable in a quieter, softer ride. 

Most importantly though, I finally picked up more horse treats, so the cookie dispensing can return to its usual, elevated rate. 

Stall rest and rationed treats are not well suited partners.

holy crap this is going to get boring in a HURRY (more wine)

Even as I was snapping my (typical) pictures of Prair standing in her stall with her head out and munching on grass - I was rolling my eyes and wondering how many more of these things I can actually take.

Activity #2

Here's one with her ears forward!

Here's one with her looking like a total nerd horse.

Here's her eating grass!

grass with our ears forward!

A new blanket on!

etc etc, FML.

So consider this a proactive apology for the EXTREME BORINGNESS that will be the blog for a while. 

Again.

In less monotonous news, Prair has had two of her shockwave sessions and is scheduled for a third and some PRP (fly money, FLYYYYY) later this month.

I also maaaaaay have an appointment with a pet psychic on the books, but that clearly is its own post...

Prair also continues to be an obedient and quiet mare so she's still getting daily turnout which makes my heart hurt a little less during this process.

However, she is beating the shit out of her wraps, so I'm investigating alternatives.  She totally tolerates her ice boots and polos, but her standing wraps are apparently a no-go.


Finally the child has started eating shoes (wtf?) and furniture.  So... more wine.

Using My Words

Thanks for all the support (and sympathetic wine drinking) I appreciate it. 

It's been a frustrating week.  My emotions ping from "eh, this is horses and I'm totally ok with that" to a totally victimized "why Prair, why…. I'll never get her sound... etc etc."

Wisely, The Boy has been traveling for work most of the week, so my cat has suffered a majority of the manic ranting. 

Basically - as awesome as Prair has been feeling since her back injections, this little (tiny) hopping action she does during her initial warm up has been nagging in my head.  It started back when we were just getting back to trot work last summer.  Prair would pop above the bridle and sort of hop (a tranter-like thing) for a step or two, especially when changing direction. 

At the time, my vet was unconcerned so I’ve consistently told myself to shut up about it and put my head in the sand. 

However, after her back injections, the hopping seemed to exaggerate itself.  She always works out of it – usually only in a lap or two, but recently it’s been more obvious when you add left leg. 

A stiff hoppy thing for a lap or two that’s unexplainable is one thing, but something that consistently shows itself with left leg?  Quite another, and much harder for me to accept.

So, I called the vet back.  And since Prair only does the hoppy thing under saddle, I tacked her up and got ready to ride. 

The good news was her left front looks spot on.  No glimmer of shortness or soreness, so big YAY there.  The bad news was that her left hind was looking like a .5 or 1/5. 

At this point I couldn’t decide if I was relieved to be dealing with a new limb or ready to cry because we were adding a new leg to the mix… but it turns out my emotional reaction doesn’t do shit for what the mare feels, so I ignored myself and waited for some flexions (that’s what the flexi-bicep emoji stood for, btw).

Everything flexed great until her Left Hind Fetlock, which she was uncomfortable even holding the flexion in. 

Then we trotted on hard ground which didn’t exaggerate any lameness on either left limb – which was moderately encouraging.

Then we took out the ultrasound machine since Vet thought the extremely bad flexion warranted a look see. (the flying money emoji)… And the world’s-longest-ultrasound commenced….And I heard my Vet say “sorry this is taking so long, but there’s a lot to look at.” 

crap.

I could not think of any possible answer that was a good explanation such a comment.

But after what felt like endless scanning and consternated looks, we sat down to talk about what she saw. 

Good News: No major tears or massive trauma that’s readily obvious.

Bad News: The medial branch of the suspensory, medial branch of the superficial flexor tendon and lateral lobe of the DDFT (I may have mixed some of those up, but there were definitely two medials and one lateral in there) all look… angry.  Some edema, minor disruption, etc.  The most concerning of the three is the DDFT which is hard to see and (my vet thinks) could be the hardest to rehab.

Ideally she wants another MRI, which, if the mare was insured would likely be covered since we are now dealing with a new limb.  But she’s not, so that’s another $3,000 and right now I’m not sure it’s worthwhile.  The first time around I was adamant about getting the MRI and not making any assumptions about what sort of injury we were dealing with.  But this time? I don’t know.  In talking it over with my vet, she can see enough on the ultrasound to want the mare on 2 months (gulp) of stall rest no matter what, and to shockwave the area. 

Part of me feels like if the MRI isn’t going to impact our treatment plan, then why stress the mare with the trip and spend the cash when it could go toward treatment.

Now, if we recheck the mare in two months and still have some questions? Maybe the value of additional diagnostics goes up. I’m not sure.  I just am having a huge mental block about loading the mare up and hauling her east again – but maybe I need to get over that. 

As for what potentially caused this? No one can say for sure, but the minor disruption and edema make it look like a slow irritation/strain rather than a traumatic sprain/tear.  In an infuriating twist of events it’s quite possible that the slight fill that Prair picked up in her hind legs from her previous stall rest was enough inflammation to lay the groundwork for this. 

I’m so frustrated.  And I’m mad at myself for not having felt this earlier.  I suppose my nagging concerns about the hoppy-warm-up-thing were silenced by how straight and balanced Prair has been.  Her changes have been nearly automatic, she’s pushing off straight over her fences (which is a new skill) and she’s so much calmer in her work, all signs have been pointing toward “comfortable.”

But clearly that is not the case. 

So, two months stall rest (she can go out in a small paddock if she’s good), with wraps on for 12 hours a day to try and keep her inflammation out.  Ice Vibes will be doing double duty on the front and hind limbs…. And that’s our plan. 

If this is truly a hiccup from having additional fill in her legs and extended stall rest, then fine, I can deal with it no problem.  But I can’t quite silence my worries that we’ve started a downward spiral of chasing soft tissues injuries from leg to leg to leg.  Fingers crossed this is a one-off and not a slow degradation of the big, lovely mare.

But that’s a bridge I’m not crossing yet.

 

 

 

Annnd Scene.

And Just like that.  We are back on stall rest.  I'd type a really detailed post about wtf is going on, but the rage is still strong, and it seems more appropriate to use emojis.



 

 

For those who don't speak emoji, I'll elaborate whenever I run out of wine and start using words again.

Red Light, GREEN Light!

Our Rehab/Training schedule these days feels a bit like a school yard game of Red Light/Green Light.  One minute we're in a holding pattern, the next we're back at it....

Prair's check up today was great.  She was a tad stiff starting out, but we experienced that earlier in her rehab and it seems to be a direct result of standing in a stall.  all..... day.... long. 

There was no sign of the weight bearing reluctance on that left front and Prair happily (and evenly) trotted tiny figure eights.

So, the current plan is - back to normal.  Still holding at 2'6", but full work to that point should be good. 

We did discuss her shoeing a bit.  I've had some concerns about how quickly her heels are contracting in the bar shoes, and I know that while the bar provides support... pinched heels cause their own heel pain.. which is counter productive...

Vet agreed, but doesn't want to change anything crazy before a show, so at her next trim, Prair will try normal shoes again, and possibly a shorter trim cycle to try and stay ahead of those heels.. Prior to the bar shoes, our farrier did a really nice job opening her heels up so I'm hopeful that will be a fairly easy process again...

Also, in really, really exciting news - Prair has been CLEARED FOR TURNOUT. 

She won't get to enjoy it until next week since we decided maybe put her back to work for a couple days (get some of the wiggles out) then let the mare go in a (small) paddock and enjoy the sunshine. 

I'm excited for her.  It's been so long. 

Two Steps Forward....

and a bit of stall rest back. 

I was *really* hoping for an all clear from the vet, and was looking forward to giving Prair some well deserved turnout...  But alas.  Not yet. 

She was stepping a tad short on the left when trotting a tight circle on hard ground.  It could be as innocent as some inflammation back in the coffin joint from all the work and the haul - or it could be some strain on that DDFT again...

Either way Prair isn't getting the turnout she wanted, and instead we're easing up for 10 days and just enjoying some long walks under saddle.  We'll reevaluate next Friday and see if she's still sore.  If yes, then.... well I don't know.  If no, then back to work (staying at 2'6") and maybe a week or two of showing in April. 

Not what I was hoping for, but a reasonable outcome.  Vet wasn't super concerned and seems to think this should be a small respite, not a huge change of direction in our rehab process. 

Still, sad face.  Poor mare wants a paddock. 

Ice Vibe Boots - The Theory

Okie Doke.  While Prair is enjoying some well deserved time off and while I sit inside since its raining in the desert (still).  Might as well geek out a bit on the latest tack ho acquisition.

The Ice Vibe Boots.  Anyone have any experience with these things? They seem super sneaky and pretty cool and I kind of wish I had pulled the trigger on them earlier in Prair's rehab process.  But no matter - no time like the present to catch up on absurd purchases :)

So the Ice Vibes.  They are made by Horseware, which means we have access to one of their direct reps (and that can be interpreted as either access to a good deal, or access to peer pressure for all the cool things).   Basically they function both as a traditional ice boot and a sonicare toothbrush.  Why the combo?  Here's a blurb from their own site:

Ice-vibe can improve the realignment of the tendon fibres during the healing process. Cooling on it's own only prevents inflammation by resisting blood flow and slows down the metabolism. Ice-vibe uses the combination of cold and vibration which minimises swelling while encouraging blood flow and speeds up healing.

(silly English spelling)

Big promises for such a reasonably priced boot...($280ish for the pair).

 

During Prair's rehab one of the biggest challenges was reducing inflammation while still encouraging increased bloodflow.  All of you who have nursed a soft tissue injury in the lower limb know how hauntingly sparse circulation is down there - and any blood flow is helpful to healing...

but inflammation on its own can cause problems... so what are you to do? 

For Prair the stall rest (and reduced movement) was the primary "anti inflammation" treatment, while fairly aggressive (and sedated) walks were how we tried to encourage increased bloodflow.  Prair stopped all anti-inflam medicine (previcox, bute, etc..) which then had me worried how to keep her back comfy during this whole process. 

Whether it helped or not, part of my plan was to just plaster the mare in Back on Track products to help increases/normalize circulation without causing too much heat... 

So this is where the Ice Vibes would have perhaps been helpful.  Cooling to reduce the inflammation, then vibration to stimulate circulation.... (Sounds like an Icy Hot commercial..)

A few ladies in the barn have tried these (one with her reiner with another trainer) and they swear by them.  Seems to be a baby version of the Theraplate... something that I've heard lots of good reviews on...

The boots have varying levels of intensity in theory for different purposes (again from their site)

Level 1 - Treatment of inflammation with cold pack
Level 2 - Rehabilitation
Level 3 - Boosts Circulation

So I like the idea of them.  Especially at long shows where Prair is potentially getting sore/tired...

Will be sure to get you a full report once I actually strap them to the pony's legs... but for now I am intrigued.

The Ultrasound - post script

Talked to vet this am, and the comparison to our December ultrasound images is even better than I thought. 

I was assuming (hoping) that essentially the tendon would look the same, but that the inflammation would prove to be new from the last 6 weeks of relatively heavy work. 

Turns out the inflammation was actually present in the same amount/areas in December so it doesn't appear to be a response to the increased workload.

Also, icing on cake?  The DDFT itself continues to look more organized and more healed than in December

So that's a big 'ol

I feel even more confident heading to Thermal knowing that working Prair 5-6 days a week- with a lot of jumping (in terms of reps, not difficulty) is still allowing her DDFT to continue healing.  Makes the months (and months... and months) of stall rest and walking seem like a great investment.

Obviously nothing is guaranteed, but it's always encouraging to see that our current strategy is (currently) working. 

Big. Sigh. Of. Relief.