by Ben Sturgeon, Bsc, BVM&S, Cert EP, MRCVS
Comedy, they say is all about… timing. Sometimes medicine is that way too. We’ve probably all heard of the patient who goes in for a routine appointment only to find and have successfully treated a life-threatening condition and of the heart wrenching tales of misdiagnosis resulting in excruciating loss of life. Lady luck is a temperate mistress and is the simple reason that I and we should ignore her influence.
There is an argument or debating tool that states “starting with the most extreme example is key” so that’s where we’ll begin. A lame horse, a big windgall (for those of you unsure of where to look, a windgall is the fluid filled swelling found around the back of the fetlock, but not of the fetlock itself), a history of intermittent but ongoing lameness alleviated by a bit of bute, a bit of rest and by a bit of benign ignorance. When finally the lameness is investigated it is found the extent of inflammation, of scarring and fibrous adhesion makes any and all therapy useless and the prognosis hopeless.
Many years ago the term “synovitis-osteoarthritis complex” was coined describing the process whereby inflammation within a synovial compartment, either by trauma, disease, excessive stress or normal stresses placed on an abnormal area results in a self-perpetuating inflammatory cycle whereby breakdown of healthy tissues results in the release of inflammatory mediators which continued the breakdown. The simple reason windgalls should not be blindly ignored is because this important synovial compartment, whilst not strictly involving any bony surfaces, is closely aligned to a number of functional soft tissues; the superficial and deep digital flexor tendons, tha manica flexoria, and the annular ligament, as well as not forgetting that the windgall itself or the flexor tendon sheath and capsule produces the synovial fluid which effectively lubricates and provides nutritive health to this complex array of tendinous and ligamentous pulleys. And this is what they effectively are, pulleys. Supporting the fetlock joint, which lest we forget, in pounds per square inch takes the greatest loading and exhibits on of the greatest ranges of motion, of any joint in the horse.
Injuries to the area can be acute and traumatic, as with almost any area, with over-reach wounds being relatively common, and if septic requiring emergency lavage of the area. However, it is more common to be presented with chronic desmitis (ligament inflammation), tendonitis and synovitis/capsulitis issues. Historically, our investigation of the area primarily encompassed ultrasonography which although useful often failed to detect subtle lesions and some longitudinal tears which carry differing treatment protocols and prognoses. The often adopted use of intrasynovial corticosteroid administration in such cases to reduce inflammation, whilst providing symptomatic relief, likely did not address the underlying issues of tendon and ligament tears or inflammations. Then with advancing fibrosis, the annular ligament was often (and still is) transacted to reduce its constrictor effect. Whilst this is a useful treatment, and can be done under standing sedation, and in selected patients i.e. overweight cobs (please note cob owners, other obese breed do regularly occur) who, as a result, abnormally load the hind fetlocks, results in very good results, the underlying issues are still neglected. The combined use of radiography with contrast to identify tears of the tendons has advanced us a step further and opened the door to potential use of biologics (stem cell and PRP for example often combined with Hyaluronic acid) as a therapeutic avenue when additionally, and vitally, combined with an appropriate tendon healing rest and exercise programme which may extend over and up to a 12 month period. Otherwise, tenoscopic surgical debridement of the frayed and torn areas, or complete transaction of the manica (often along with the annular ligament) is undertaken although again prognoses for full return to athletic performance vary depending upon the site and severity of the tear and the chronicity of the condition.
Whilst I generally abhor government led policies dictating health and medical care for the masses ignoring the individual nature of medicine, the aims of routine health care cannot be denied and no doubt have extended our own longevity and reduced health care costs. The same can be said of horses. Whilst windgalls are an extremely common finding, their recording of size, position, firmness, relationship to exercise, involvement of lameness etc should be noted and perhaps added to the list of “to do’s” with annual vaccinations and general health checks. For those where high level performance is anticipated (that generally means 90% of all horse owners who own or are related to Farlap or some other notable winner via the second cousin twice removed) or expected, their finding should, whilst not raising alarm bells or promoting sleepless nights, bring into consideration exercise programmes, farriery and use of joint supplementation or biologics to promote career productivity and longevity. To the rest of us, don’t let lady luck act as your diviner, kick her out and put the decisions in your own hands.