Part 1 of 3
by Jessie Bengoa
This article is sponsored by Platinum Performance®
Article originally appeared here: https://www.platinumperformance.com/articles/connectivity
From injury prediction and prevention to treatment and rehabilitation, leading veterinarians are advancing the science of maintaining and healing tendons and ligaments in the horse.
Featuring Veterinarians Dr. Lisa Fortier, Dr. Carter Judy, Dr. Jackie Hill and Dr. Santiago Demierre
Soft tissue injuries are amongst a horse owner’s most dreaded fears and a veterinarian’s greatest challenges. Not long ago, a horse’s performance career was almost entirely lost when they sustained even a moderate soft tissue injury. An injury to the deep digital flexor tendon or suspensory ligament, for example, was career ending in many cases, rendering previously high-level equine athletes virtually unrideable.
In the last two decades, science has leapt forward, advancing the understanding and treatment of equine soft tissue injuries to a level of renewed hope. Diagnostic imaging and surgical capabilities have evolved considerably, regenerative medicine has redefined the limits of healing, nutrient therapy has given veterinarians a valuable tool to help improve patient outcomes and the science of rehabilitation has become a critical component in successfully returning horses to work post-injury.
Soft tissue injuries of the fore and hind limbs include the vital tendons and ligaments that give horses their athletic power and wide-ranging capabilities in varying disciplines. Tendons function by connecting muscle to bone while ligaments connect bone to bone, with each being imperative to performance and carrying its own challenges when injured. Along with the monumental leaps that have been made in veterinarians’ abilities to diagnose, treat and rehabilitate these injuries, there is a bright future ahead that promises a new frontier in the science of injury prediction and personalized treatment.
Diagnostic Imaging
Magnetic Resonance Imaging (MRI)
Perhaps one of the greatest factors in determining the prognosis for a soft tissue injury is in obtaining a proper diagnosis from the outset. With vast improvements in the field of diagnostic imaging, today’s veterinarians have the advantage of accurate information and a better understanding of the scope of the injury. MRI is now seen as the gold standard in diagnostic imaging related to orthopedic injuries. “MRI utilizes a strong magnetic field — 30,000 times as strong as the earth’s magnetic field — to orient the atoms of the body,” explains Dr. Carter Judy, a boarded surgeon at Alamo Pintado Equine Medical Center in California, who is widely recognized as a world leader in reading and interpreting MRI results in the horse. “By changing this field temporarily, these atoms react and emit radio waves, which are detected and interpreted by a computer to create the image,” he says. “No radiation is used, and there are no known side-effects to the use of MRI at this field strength in the horse. At Alamo Pintado, we use a high field (1.5T) Siemens Magnetom Espree. This system allows for effective, time-efficient imaging of orthopedic, soft tissue and head/ brain pathology of the horse.” The use of MRI has drastically changed veterinarians’ capabilities in terms of properly identifying, then treating soft tissue injuries in a more timely manner. “This has been a game changer for so many horses that were previously going undiagnosed for a long time,” says Dr. Jackie Hill, a boarded surgeon at Littleton Equine Medical Center in Colorado.
Ultrasound
In addition to MRI, ultrasound has been a valuable tool in both a clinic and field setting for over 30 years. Ultrasound today provides veterinarians with a highly adaptable and often portable diagnostic option ideal for capturing the longitudinal plane. “Today we have access to very handy and easily usable ultrasound machines that have improved image quality dramatically,” says Dr. Santiago Demierre, an Argentine-born veterinarian who sees a significant amount of soft tissue injury cases in practice at Palm Beach Equine Clinic in South Florida. The son of a racehorse breeder and a polo player himself, Dr. Demierre is intimately familiar with the angst owners and riders experience when their horses are diagnosed with a soft tissue injury, riding the wave of treatment and rehabilitation while hoping for the best of outcomes.
Shear Wave Elastography
While diagnostic imaging has seen exponential improvements in recent decades, the work to further its reach has continued. “There is work happening in Japan with the Japanese Racehorse Association in the area of shear wave elastography that looks very promising,” says Dr. Lisa Fortier, a boarded surgeon and highly respected researcher at the Cornell College of Veterinary Medicine. “This technology tells you the actual mechanical strength of the tissue. It is an expensive form of ultrasound commonly used to tell you the stiffness of different tissues,” she explains. “For instance, if you are ultrasounding different tissues and you have a scar, then it will be stiffer than normal, where a mineralization would be even more stiff.” While the technology is promising and used more widely in human medicine, its transition to veterinary medicine is expected to be slower due to the expensive nature of the tool.
While treating soft tissue injuries requires a multi-faceted approach, the process begins with swift and proper diagnostics. Due to advancements, such as MRI and ultrasound, and novel technologies like shear wave elastography, injured horses are now able to begin a targeted treatment regimen earlier, paving the way for greater success.
Surgical Advancements
Once an equine patient is properly diagnosed with a specific soft tissue injury, surgery becomes an option with select cases. Dr. Hill uses a variety of surgical techniques to offer patients the best opportunity for recovery, including both tenoscopy and bursoscopy. “Tenoscopy is a technique similar to arthroscopy,” she explains. “With tenoscopy, we use a small camera, but instead of viewing a joint, we are viewing a tendon sheath, which is the area filled with fluid that surrounds the tendons and ligaments. This approach allows us to take a look inside and either clean up some tears or repair things in a minimally invasive way.” In contrast, bursoscopy looks directly in a bursa, which differs from a tendon sheath because it does not completely surround the tendinous structure and is located on only one side of the tendon, between it and a bony prominence. Bursoscopy is commonly used for injuries deeper down in the foot, such as in the navicular bursa. “In this case, we again use a small camera to look into the bursa to be able to treat and diagnose those injuries more accurately,” says Dr. Hill. “There is also the needle arthroscopy, and while we don’t use it frequently, it allows us the ability to arthroscopically look in a stifle joint with an 18-gage needle,” she explains. Regardless of the surgical method chosen, the quality and capabilities of surgical equipment have given veterinary surgeons significantly greater reach in the operating room. While surgery is often a vital step in a horse’s recovery from soft tissue injury, there are numerous other options that have each played a role in improving a horse’s ability to return to work after suffering a tendon or ligament injury.
At left, Magnetic Resonance Imaging (MRI) is now seen as the gold standard in diagnostic imaging related to orthopedic injuries. Soft tissue injuries of the fore and hind limbs include the vital tendons and ligaments that give horses their athletic power and wide-ranging capabilities in varying disciplines. In the last two decades, science, including diagnostic imaging, has leapt forward and advanced the understanding and treatment of equine soft tissue injuries to a level of renewed hope. At right, Dr. Santiago Demierre, of Palm Beach Equine Clinic in South Florida, takes an X-ray of the hind, knee-joint of one of his patients.
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