Vet case study: a torn suspensory and digital flexor tendon [H&H VIP]
The horse
Ellie, a 16.2hh Irish Sport Horse aged 20 (born 1993), was showjumping up to discovery level with her owner of 8 years, Erica, before her injury. Although she is now fully recovered and can still jump up to 1m, Ellie is now enjoying her senior years as a happy hacker.
The history
In June 2012, during a jumping lesson, Erica noticed that Ellie was not her usual self. A horse who was “usually very forward” was now quiet and “trippy” and although Ellie was not noticeably lame, Erica knew something was awry. She immediately called her insurer, Petplan, who assured Erica that she was covered and could go ahead and call her vet.
Ellie was examined by a local vet who diagnosed suspensory ligament damage to her left-fore. The vet’s immediate advice was to give Ellie bute alongside a few weeks off. This proved unsuccessful, Ellie was still not right, so Erica took her to the same vet for an x-ray.
This showed that although Ellie was only one-tenth lame, her suspensory ligament was torn. The vet was concerned about the likelihood of the mare being able to return to ridden work at all. Erica refused to put Ellie down and instead decided to give her 6 months off over the winter.
Treatment
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Following this time-off, Ellie was still lame and, having spoken again with her insurers, Petplan (see below), Erica took her to see Neal Ashton, a soft tissue specialist at Oakham Veterinary Hospital. Neal watched Ellie on the lunge and then used an ultra-sound scan, which showed that there were in fact 2 separate injuries.
The first was tearing of the suspensory ligament close to where it meets the fetlock joint, and the other was a tear to the centre of the superficial digital flexor tendon where it meets the back of the knee joint. Both injuries were long standing and it was clear that they were not healing.
After discussing the options with Erica, Neal went ahead with surgery, putting Ellie under general anaesthetic. Firstly, he identified the suspensory ligament lesion and used keyhole surgery at the fetlock joint. The tear was “open” meaning that loose ligament fibres “float about within the joint fluid” and, therefore, cannot heal.
Neal used suction and cutting to remove the frayed elements and then injected PRP (platelet rich plasma), made in the Oakham Veterinary Hospital’s own laboratory, into the lesion. PRP is a product of the injured horse’s blood, with the growth factors in this blood highly concentrated in order to aid tissue regeneration.
Neal then began keyhole surgery on the second tear, a complicated process as the lesion was in the middle of the tendon rather than on the surface. The tear was also extremely close to the knee joint and the high check ligament. Neal sectioned the latter, releasing its attachment to the back of the knee and therefore relaxing the flexor tendon, giving the knee joint more elasticity. Neal then injected PRP into the lesion.
Neal made it clear that although every horse is different, leaving the injury to heal on its own does not always work, and PRP is a great way of giving the horse’s healing process a “kick up the backside”. The most important point in Neal’s diagnosis is to find out why the wound is not healing and to find an appropriate treatment for this, depending on what the horse’s future use is eg to jump, race, or hack.
After the operation, the Hospital advised Erica to send Ellie to a rehabilitation centre where there would be physio available and a spa. Erica decided against this option as Ellie was visibly distressed at being away from home and had lost weight from the ordeal.
Once Ellie was home, Erica followed Neal’s long and meticulous treatment plan of combining rest with controlled exercise. This began with 8 weeks of box rest. Ellie needed a little sedation at first as her entire leg was bandaged and very restricted movement was necessary.
Ellie was then allowed into a very small sectioned-off area of her field, which Erica moved on to fresh grass every few days. The vet made it clear that every element of Ellie’s treatment must be carried out extremely slowly in order to give her the best chance of recovery.
When Erica came to ride her for the first time, 14 weeks after the operation, she was instructed to go straight to road work, as Ellie’s legs needed resistance rather than soft ground. The roads would “load” and stimulate the ligaments, with Neal suggesting an initial 20-minute walk, building up to 1.5-hour walks, on roads every day for 8 weeks.
Hill work was also added to the routine, with Ellie finding it particularly difficult to go downhill due to the pressure this put on the suspensory ligament.
After eight weeks, Erica could develop this exercise to incorporate 2min of trotting, although still only on roads. After 12 weeks of road work, 26 weeks after the operation, Erica could finally take Ellie on to soft ground and, after a couple of weeks, they went for a gentle canter. A month after they started riding on soft ground, they could jump again.
The food
After Ellie’s operation, Erica knew it was essential to change her food as she was extremely thin, but was also on box rest and had limited means of exercise. Erica rang the Allen & Page advice line so that she could explain her situation and needs fully, rather than trawling through the endless options on suppliers’ websites.
Their expert suggested that Erica begin feeding Allen & Page’s Veteran Vitality, which Ellie immediately loved. It added condition without making her fizzy, and Erica was so pleased with it that she stuck with this feed long term.
The outcome
Erica slowly and steadily built up Ellie’s workload until they were jumping again; with Ellie now back to clearing 1m. The whole process, from injury through to full recovery, took Erica and Ellie just over 14 months.
Erica made the difficult decision to sell Ellie at the end of October 2013. Erica wanted to continue showjumping competitively, and felt that Ellie deserved to retire to a slower pace of life with someone suitable. Ellie now has the perfect lifestyle for her age, as a hack, with Erica only an hour’s drive away.
Because Ellie was 19 when her injury occurred, Erica said that “everyone seemed to write her off” and she felt that most people would have put Ellie down. However, Ellie is proof that horses can recover from this injury, but it does take a great deal of time and patience. Erica is incredibly pleased with Ellie’s full recovery and would encourage others not to give up on a horse with suspensory ligament or tendon damage.
The costs
When a vet advises that treatment is likely to be expensive, the owner is understandably anxious to know whether this will be covered.
Ellie was insured with Petplan and Erica contacted them at the first sign that something was amiss with her horse, and remained in touch with them throughout her treatment. Erica was worried about the costs as the injury developed. Petplan suggested that Erica fill out a ‘pro-forma’ before Ellie’s operation.
This is effectively a ‘dummy claim’ which outlines the approximate price of treatment and which Petplan can assess this as they would a formal claim, aiming to respond to the client within 72 hours with their decision.
If Petplan consents to cover the cost of the treatment, this will be guaranteed. An owner can only achieve this certainty of coverage through this official process rather than over the phone, as the insurer is given the time to assess the case fully.
Ellie’s operation cost £3,000, with Petplan paying £5,000 for all the treatment costs.
Contacts:
Vet – Neal Ashton at Oakham Veterinary Hospital – 01572 722647
Petplan – www.petplanequine.co.uk
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