Proximal Suspensory Ligament Desmitis - :: Pioneer Equine

1 Proximal Suspensory Proximal Suspensory Ligament DesmitisLigament DesmitisLuke Bass, DVM, MSLuke Bass, DVM, MSSignalmentSignalment 9 yr old QH gelding9 yr old QH gelding Function: Barrel racing Function: Barrel racing (nationwide)(nationwide)HistoryHistory Forelimb fetlock joint injections, chiropractic adjustments, andForelimb fetlock joint injections, chiropractic adjustments, andacupuncture acupuncture 5/055/05--LH lameness (2+/5) blocked to TMT jointLH lameness (2+/5) blocked to TMT joint RadsRads--No Significant findings No Significant findings Stall rest and NSAID Stall rest and NSAID 6/05 6/05 Chronic LH lamenessChronic LH lameness Nuclear Scintigraphy Nuclear Scintigraphy DIT & TMT injectedDIT & TMT injected 4/064/06--RH lamenessRH lameness Chiropractor adjustment & acupunctureChiropractor adjustment & acupunctureHistoryHistory 5/06 5/06 --LH lameness (2/5), + flexions, LH fetlock joint block LH lameness (2/5), + flexions, LH fetlock joint block (70%)(70%)

2 LH fetlock injectedLH fetlock injected 7/067/06--Lameness unchanged, LH fetlock U/SLameness unchanged, LH fetlock U/S SSL & OSL fiber disruptionSSL & OSL fiber disruption 8/068/06--ESWT ESWT --LH fetlockLH fetlock 8/068/06--LH lameness LH lameness --70% improvement with fetlock block70% improvement with fetlock block Diagnostic arthroscopy Diagnostic arthroscopy HistoryHistory 1010--12/06 12/06 --Chiropractor adjustment, acupunctureChiropractor adjustment, acupuncture 2/072/07--Bilateral lameness; moderate OA changesBilateral lameness.

3 Moderate OA changes Both hocks were medicatedBoth hocks were medicated 2/072/07--Chronic LH lameness, + flexionsChronic LH lameness, + flexions Proximal Suspensory blockProximal Suspensory block U/S U/S --enthesiophyte @ origin, suggested MRIenthesiophyte @ origin, suggested MRIU ltrasoundUltrasound Mild Desmitis - Origin of the LH SL Mild enthesopathy- Origin of the LH SL MRI and Surgical treatmentMRI and Surgical treatment LHLH--Acute desmitisAcute Desmitis --thickening, focal bony resorption at that thickening, focal bony resorption at that origin on MT3, and fluid in origin MT3 & MT4 origin on MT3, and fluid in origin MT3 & MT4 RHRH--Chronic desmitisChronic Desmitis --Thickened, severe scarring (scout images)Thickened, severe scarring (scout images)

4 DecisionDecision--Bilateral plantar fasciotomy and neurectomyBilateral plantar fasciotomy and neurectomyMRIMRIM oderate enlargement Origin of SLScarring to SL - Previous injury MRIMRIT enosynovitis RH tendon sheathChronic PSLD in RHMild degenerative LH SLAcute PSLD in LHForelimb Proximal SL DesmitisForelimb Proximal SL Desmitis 44--12 cm DACB12 cm DACB Acute casesAcute cases--Pain and swelling in regionPain and swelling in region Chronic casesChronic cases--No palpable abnormalitiesNo palpable abnormalities Positive distal limb flexionPositive distal limb flexion--50% of cases50% of cases Lameness accentuated on circle, extended trotLameness accentuated on circle.

5 Extended trot Foot imbalance Foot imbalance predisposing factorpredisposing factorPerineural AnesthesiaPerineural Anesthesia Lateral palmar nerve Lateral palmar nerve --Medial and lateralMedial and lateralpalmar metacarpal nervespalmar metacarpal nerves Ensures that carpal joints Ensures that carpal joints are not inadvertantly injectedare not inadvertantly injected Palmar outpouching of CMC Palmar outpouching of CMC joint > TMT jointjoint > TMT jointHindlimb Proximal SL DesmitisHindlimb Proximal SL Desmitis 22--10 cm distal to TMT joint10 cm distal to TMT joint Pain on palpation of Proximal SL (acute)Pain on palpation of Proximal SL (acute) Persistent lameness post restPersistent lameness post rest Hock flexionHock flexion--Accentuates lameness (85%)Accentuates lameness (85%) Infiltration of anesthetic Infiltration of anesthetic Origin of SLOrigin of SL--Possible diffusion to TMT jointPossible diffusion to TMT joint Conformational abnormalities Conformational abnormalities --(21%)(21%)

6 Perineural AnesthesiaPerineural Anesthesia Subtarsal nerve blockSubtarsal nerve --TMT jointTMT joint--50% 50% --Tarsal sheathTarsal sheath Deep branch of lateral Deep branch of lateral plantar nerveplantar nerve--0% 0% --TMT jointTMT --Tarsal sheathTarsal sheathCompartment SyndromeCompartment Syndrome Enlargement of SL Enlargement of SL pressure to MT bones, pressure to MT bones, plantar plantar MT nervesMT nerves Persistent pain and lamenessPersistent pain and lameness Early diagnosis and therapy to reduce size and Early diagnosis and therapy to reduce size and minimize inflammationminimize inflammation Current opinions refute this as 1 Current opinions refute this as 1 problemproblem--Ongoing neuritis due to inflammationOngoing neuritis due to inflammationCompensatory DesmitisCompensatory Desmitis Ipsilateral forelimb w/ 1 Ipsilateral forelimb w/ 1 foot lamenessfoot lameness Contralateral

7 Fore/hind Contralateral fore/hind --overload injuryoverload injury Forelimb ipsilateral to Forelimb ipsilateral to 11 hind lameness hind lameness --pacerspacers Contralateral forelimb (LH, RF) Contralateral forelimb (LH, RF) --trotterstrottersDifferential DiagnosisDifferential Diagnosis Middle carpal joint painMiddle carpal joint pain--young TBsyoung TBs DJD of middle carpal jointDJD of middle carpal joint Palmar cortical fatigue fracturesPalmar cortical fatigue fractures--MC3MC3 Avulsion fracturesAvulsion fractures--origin of SLorigin of SL TMT painTMT pain Primary stress reactions of MT3 Primary stress reactions of MT3 Radiographic FindingsRadiographic Findings Sclerosis of MC3, lateral MT3 Sclerosis of MC3.

8 Lateral MT3 --DP viewDP view Enthesiophyte formation, subEnthesiophyte formation, sub--cortical cortical sclerosis sclerosis Lateral viewLateral view Hindlimb > ForelimbHindlimb > Forelimb R/O avulsion fx MC3/MT3R/O avulsion fx MC3/MT3 Changes Changes rare in acute casesrare in acute casesUltrasonographic Findings Ultrasonographic Findings Enlargement of the Suspensory Ligament Enlargement of the Suspensory Ligament Poor definition of dorsal marginPoor definition of dorsal margin Central core lesionCentral core lesion Larger area of diffuse hypoechogenicityLarger area of diffuse hypoechogenicity

9 Focal demineralizationFocal demineralization Examination of contralateral limbExamination of contralateral limbNuclear ScintigraphyNuclear Scintigraphy Unnecessary for diagnosisUnnecessary for diagnosis Bone turnover at insertion of SLBone turnover at insertion of SL No uptakeNo uptake Abnormal uptake w/ no U/S changesAbnormal uptake w/ no U/S changesMRI FindingsMRI Findings Enlargement/abnormal high signal intensity in Enlargement/abnormal high signal intensity in ligamentligament Bone injury Bone injury --Fluid in bone at insertion site Fluid in bone at insertion site Comparison to contralateral limb Comparison to contralateral limb images side images side to sideto sideMRI FindingsMRI Findings Axial PD imagesAxial PD images High signal in PSLHigh signal in PSL Axial STIR imagesAxial STIR images High signal in MT3 High signal in MT3 PSLD TherapyPSLD Therapy Severity of lesionsSeverity of lesions Level of competitionLevel of competition Urgency of upcoming competitionUrgency of upcoming competition Financial contraintsFinancial contraints

10 Recurrence of problemRecurrence of problem Prognosis for forelimb > hindlimbPrognosis for forelimb > hindlimbPSLD TherapyPSLD Therapy Stall rest and support bandages w/ slow return Stall rest and support bandages w/ slow return to exercise (forelimb > hindlimb)to exercise (forelimb > hindlimb) Corticosteroid & PSGAG therapyCorticosteroid & PSGAG therapy Shockwave therapy Shockwave therapy --3 treatments3 treatmentsPSLD TherapyPSLD Therapy Bone marrow injection Bone marrow injection AA--cell vs stem cell injectioncell vs stem cell injection Internal blisterInternal blister ShoeingShoeing--Support fetlock w/o raising heelSupport fetlock w/o raising heelHindlimb PSLD TherapyHindlimb