"And, when you want something, the entire Universe conspires in helping you to achieve it." -The Alchemist, by Paulo Coehlo



Saturday, September 13, 2014

Gracie's Fall

The Tuesday after Labor Day, I decided to take Gracie for a spin in the back fields for our morning ride.

I had no goals for this day, no grand mileage nor speed that I wanted to achieve. I pulled Gracie from the field and assessed her mood, expecting her to be hot and sassy after 3 days off in a row. She was not. It was a blazingly hot day, one of those days in the high 90's where just being in the sunlight makes your skin prickle. Gracie was happy but very relaxed, obviously suffering from a case of the summer doldrums. I used to longe her prior to riding after a couple of days off: she sometimes needed a reminder about who is the alpha in our relationship, something that only took about 10-15 minutes to ingrain again in her blonde head. I haven't had to do that in a while now and looking at her on this day, I knew it wouldn't be necessary. So I just tacked her up and hopped on with the intention of just working for 30 minutes, since it was so freaking hot out.

I just get these gut feelings about things. I don't know. All I know is that on this day, I decided to just ride in the flat field. I tend to warm up there and move on into the other fields, but something motivated me to just do the brunt of our session there. The footing is pretty smooth, made up of hard clay under grass that has been mowed short.

I made our goal for the day to work on collection. We worked on straight lines and bending lines, on circling and serpentines. Gracie was a rock star, fluid and attentive. She was on fire like she usually is, but no sassiness or disobedience from her. She felt rock solid.

We had already been working for 15 minutes or so when we went around the far side of the field. Where the footing is smooth. And Gracie suddenly tripped hard with her left front. My heart went into my throat as she stumbled hard and went down on her knees, floundered once in her attempt to get up, crashed down to her knees again and almost lost her balance on her hind legs, then managed to get both front legs under her and stand up. All of this happened in a split second. I somehow stayed on during all of that, a part of my brain thinking in slow motion, "Maybe...I...should...bail...". I never did though. It was like my body was glued to the freaking saddle. As soon as she was up again, she moved on into a trot and I asked her to come back into the collected gait because there was no way in hell I wanted her in a lengthened frame after an epic stumble like that one.

Gracie gaited for a few strides, then came to a halt of her own accord. I was pretty shaken up over what had happened, thinking over and over, "What if she'd fallen all the way? Would I have been able to get out of the way in time?" I stroked her neck for a minute, then sat back and asked her to continue. I figured if something was really wrong with her, she'd let me know and refuse. She's that kind of mare.

But she didn't. She happily picked up her gait and we continued working on bending and circling. We rode through the same spot a couple of times and she didn't trip at all.

For whatever reason, after all that, it suddenly seemed like a great idea to go down to the hilly field and work on faster gaiting up the hill with collection on the down sides. I can't even begin to remember why exactly that seemed like something that should be done on this particular day after what had just happened. There was some sort of logic involved, but I can't tell you guys what it was.


So anyway. Off we went to the far field with the hill. Yes, it was not one of my brightest moments, but at the same time, this hill is barely a hill. It's more like a slight slope. It's a hill when you compare it to FL. It's a joke when you compare it to WV. I mean, there's a total of a 50 foot altitude gain in these fields. That's not really something that you'd call hills.

See? This is the field I'm talking about. 
Gracie was happy to go and she wanted to attack the hill at a faster gait, but I had her go up at her medium gait, and come down at her most collected gait, almost walking. There are some lumpy spots in this field, enough that Lily, the more graceful one, will give the occasional trip in them and become extremely annoyed (if you've never seen a horse get mad at themselves for tripping, you all should watch Lily. She gives a little hop of frustration and pins her ears. It's freaking adorable.) I was making a point of avoiding these spots with the G-mare though.

We were on our second or third loop and had just reached the bottom of the field. There's some clumpy grass there, but the footing is solid.

Gracie's left front suddenly got caught underneath her and she never really had time to attempt to place her right front to catch herself. She literally bit it. She went down chest first and to the left. I didn't even have time to think about bailing because it was so sudden. I went flying in the general uphill direction, cringing at the idea of getting crushed, and felt when she fell on my left foot. I turned to look at her and she was already standing up. And then she was back up on all 4 feet, looking very upset at what had just happened. She stood for a moment, head down, and I got the impression that she was assessing herself to make sure everything was okay. She then came over to me and I saw the concerned expression in her eyes as she stuck her nose in my face and sniffed me over, "Are you okay?"

"Oh Gracie." I said. I sat up, realizing that nothing hurt. The foot she'd fallen on was fine. I had a scrape at the front of the ankle and my right knee hurt in such a manner that I knew I'd have a bruise. I think I got walloped by one of the metal stirrups of her saddle.

Gracie, who will eat any food in sight, was surrounded by an ocean of grass and she chose to stay next to me. She didn't even try to eat. She was hanging her head in what looked like shame. :( I rubbed her neck and told her it was not her fault and she perked up. I then looked her over and proceeded to do a quick neuro exam on her, making her turn tightly on her haunches, having her walk backwards with her head up, crossing her legs to see if she could uncross them. Everything was absolutely normal.

I didn't get back on. I led her back into the barn, switched her bridle for a rope halter and lunge line, and led her back to the same spot where she had fallen in the field. I had her trot and canter around me, trying to see if she would trip again. She did not. She trotted and cantered both uphill and downhill without a problem, and even did this gorgeous rack on the lunge: a first.

Hmmm...

I cooled her off and took her back into the barn to hose her off.

She had a day off, then on Thursday I took her out on the lunge again and worked her over ground poles. I figured if this was a coordination issue, she would have a problem with ground poles. She did not. She was even tracking up beautifully.

Warmup with side reins
That's when I called the vet and scheduled an appointment for the following Friday. My vet has been slammed and I knew she wouldn't be able to come immediately the next day and I didn't want the appointment to be on a work day during the week, so Friday it was.

It is not normal for horses to fall. Horses will do anything to avoid falling because in the wild falling = death when predators were involved. If the footing is iffy and you're going at speed or doing crazy stuff like jumping cross country or even regular fences in deep sand, then that's a whole other type of scenario. But falling on flat natural footing is a big red alert on an otherwise normal horse. Especially if said horse has fallen more than once. Some horses are clumsy and will stumble often, especially horses that are used to being ridden in manicured footing. But falling is never normal. Any horse that falls more than once in a short period of time (weeks, months), should ideally be promptly evaluated by a veterinarian to rule out things like an orthopedic problem or neurological disease.

Gracie got lunged for half hour sessions last weekend. Gaited horses can be very hard to assess in motion because a lot of the time you aren't sure if they're really lame or just doing a weird inbetween gait, unless of course they have an obvious head bob. But I noticed during these sessions that Gracie was stepping short with her right front at the beginning of the workout. She would also blink every time that foot hit the ground (if you have a doubt about a lameness, watch your horse's eyes: they will blink every time that foot hits the ground. Really). The initial short striding was the same regardless of footing. There was no head bob, just a short stride for a turn or two on the lunge that would appear and disappear a few times for the first 10-15 minutes of work while warming up, then disappear entirely once she was really going. The blinking would also stop at this point.  I had thought I'd seen this in the past, but had thought she'd been doing a weird inbetween gait. It was subtle enough that you couldn't feel it under saddle. I could confirm it now though: she was definitely stepping short on that leg as she warmed up.

Mistified, I simply gave her this past week off. Part of it was that I was exhausted due to other things going on, and part of it was an experiment: if she got better, it was probably an injury of some sort, maybe soft tissue. If she got worse with rest, then she most likely had arthritis. Pain in the right front would explain why she couldn't catch herself with that leg every time she's tripped in the past. She always trips with the left front, then has a hard time catching herself with the right front.

I went out to the barn during the week before work to groom and set up feed, but I did nothing else. My vet came out this Friday. I told her everything that had been happening:

  • I'd been told G-mare has stifle issues by both her trainer and her previous owner and I'd been working on rehabbing her for that. 
  • Initially her hind end would trail while at work; she is now MUCH more able to step underneath herself both on the lunge and under saddle. I mentioned I have video of "before" and "after" on my phone if the vet needed to see them.
  • She tightrope walks with her hind end and swings her LH medially more than the RH. It used to be very pronounced and has improved with work.
  • She works MUCH better and is MUCH more sure-footed on rough terrain vs flat terrain. She even gaits better. I always feel  safe when I'm riding her (Gracie is opinionated but she doesn't have a mean bone in her body) and a big part of that is because she is overall so surefooted 99% of the time. 
  • About 2 months ago, she tripped in the deep footing of the arena going left on the left lead in the corner. She tripped with her LF and had a hard time catching herself with her RF. She did fall to her knees.
  • She did the same thing again while on the lunge a few weeks ago, also while going left. The footing in the field was a little slippery and she was being an idiot at the time, but again she tripped with the LF and had a hard time catching herself with her RF. Again fell to her knees. 
  • This is exactly what happened on the day she fell while I was riding.
  • She seems to step short on the RF on the lunge then warms up out of it. No head bob. Can't feel it US, and it was subtle enough for me to think I was imagining it when seeing it on the lunge.

Dr. L listened attentively to the whole saga, repeating the significant parts of all of this out loud. She is the best. (Seriously: we have some really wonderful vets in this area. Dr. R was fantastic too but the practice owner had raised their already high prices significantly at the beginning of the year which is why I'd switched to Dr. L, our current barn vet.) I pulled Gracie from her field.

Dr. L checked her right foot with hoof testers first, and she was negative. We then put G-mare on the lunge in one of the fields. I was surprised to see how much worse the lameness was: she was slightly head bobbing now at the trot. I mentioned that Gracie had been rested this past week. All Gracie does in the field is stand all day in the run-in when she's wearing her grazing muzzle (seriously Mare: the point of field board is that you move around) and just walks around eating at night. She's not one of those idiots that randomly runs around like a lunatic. She loves to work when people are involved, but on her own she is all for the conservation of energy.

After this, we did flexions with trot-outs. Gracie was positive for the fetlock flexion of her RF. Dr. L had me walk her around to allow the soreness to go away, then flexed Gracie's knee. No change. Okay: we had narrowed the lameness down to somewhere below her fetlock.

We then proceeded with nerve blocks. I want to point out that, while Lily basically tried to kill my vet when we did this to diagnose her injury last year (she had to be drugged AND twitched just for the nerve blocks!) Gracie was an absolute saint. I had her stand next to me and stroked her forehead while the vet put needles in her heels. It wasn't for lack of sensation: she could feel the occasional flies on her leg and twitched her skin, but she held that foot still when Dr. L requested her to. We then had her wait while the medication kicked in. Gracie was happy to just stand with all feet square right next to me, eyes closed while I scratched her neck. Once the foot was good and numb, I had her trot around on the lunge going to the right.

No significant improvement. Dr. L mentioned that G-mare was doing such weird things with the LF to compensate for the RF that it distracted her there for a minute. This is why, even if you work in the veterinary field, it is always recommended that you bring out a vet to look at your horse if something is off: not just for the experience but also for the fresh eyes. You get used to seeing small weird things about your horse over time. I couldn't see what Dr. L was seeing with Gracie's LF, but it would certainly explain why she was tripping with that foot: it was part of her compensatory mechanism to protect the RF.

So Dr. L blocked the fetlock. And Gracie trotted out sound. When she realized that her foot didn't hurt, she arched her neck and stepped out extravagantly. I had to laugh at her. Goofball mare.

Next up: x-rays.

We had Gracie stand on the wooden blocks and took 2 views of her RF. And we found the culprit, which was as I'd suspected given what we had been seeing so far:



Arthritis. Specifically: ringbone. High ringbone.

Diagram of low ringbone vs high ringbone.
And I never would have seen it on the above radiographs if the vet hadn't pointed it out. We took a view of the sound LF for comparison and here the differences are a little more evident:

On the left is Gracie's sound LF. On the right is the lame RF.
These are terrible phone pictures of the images on Dr. L's screen, but you can see some of what we were seeing.
Red circles on RF: Do you see those pointy edges? Look where the green arrows are. Compare to the same edges in the blue circles on the LF. Yup, I never would have caught that either! Also look at the red arrows. There is a slight narrowing of the joint space on the RF when you compare it to the LF. This is why she's stepping short on this foot, why she warms up out of it, and why she got worse after a week off work. She stumbles on the LF because she is over-using it to compensate for the RF, and she is not able to catch herself with the RF because it hurts.
Am I upset? Not at all!! Kathy, Zoey and BO had been gathered around listening, and they all looked devastated for me. I was just so upbeat. All I could think was; "It's not neuro! *Relief*" I don't need to compete this mare to be happy with her. She is one hell of a horse. All I wanted was to be able to keep her in work. The mare loves attention and thrives on having a job. Even the previous week when we were just doing work on the lunge, she understood that this was her job for the moment and she was all, "Let's go!" Early retirement would have been, I think, even more devastating for her than for me.

Zoey had been holding Gracie while I sat on the floor next to Dr. L to discuss the rads and options. Gracie had been slowly gravitating towards me and I didn't notice what was going on until I heard Zoey say to the G-mare, "You love your mommy, don't you?" And I look up to see Gracie's face right next to mine, eyes twinkling. I rubbed her forehead while listening to Dr. L and the blonde closed her eyes.

This is what I mean.

Okay, so I know all of you have probably heard of ringbone at some point or another. This is what an advanced case looks on x-ray:

Yellow arrow is pointing at the much more advanced case of ringbone in this horse. Red arrows are pointing at sidebones, which coincidentally Gracie also has. I'd never seen them on x-ray on a horse before and I'd read about them as being a problem. Dr. L said they are more common in drafts, but given the fact that Gracie has them on both fronts and they are identical on both feet, they are simply an incidental finding and in her case a genetic trait. They're usually a problem if they do something stupid like fracture.
High ringbone on another horse. I'm not including Gracie's lateral shot because it came out very fuzzy on my cell phone pic, but it was very boring. Thankfully. We like boring x-rays.
So you can see how very early Gracie's is!

And what are the options? My vet went through all of them with me.

a) Disease-modifying therapies:

  • IRAP - this is the gold standard for treating osteoarthritis. IRAP stands for interleukin-1 receptor antagonist protein, and is more recently being called autologous conditioned serum (ACS). When done early, IRAP can significantly delay the progression of degenerative joint disease. If you want to read the details about how it's done and how it works in laymen's terms, go here. I was surprised to discover that my vet provides this therapy and that, while expensive, it is not as insanely expensive as I had originally thought. I had read about IRAP in the past and thought that it was something that was only done at the big equine clinics and thus, because of the price point, was a treatment limited to upper level performance horses. I was wrong on both counts. Good. Treatment starts with a series of 3 injections in the joint, and then you maintain after that. The average horse needs an injection every 6 months for maintenance. 
  • Oral joint supplements -  with glucosamine, chondroitin and hyaluronic acid, preferably in liquid form, as they are more readily absorbed by the body. My vet recommended Actiflex 4000 in particular, which I've seen other people use successfully in the past. I tend to steer away from liquid supplements because I have to pre-make my grain rations and liquids make a huge mess, but we'll do it for Gracie.

b) Symptom-reducing therapies:

  • Intra-articular steroid injections: betamethasone is preferred in a horse that can potentially have metabolic issues, as there are less systemic side effects. These are often used secondary to IRAP. 
  • IM injections of products like Pentosan, Chondroprotec (used off-label; it is basically a generic Adequan) or Adequan 
You can also inject stuff like Legend into the joint. Dr. L mentioned that recent studies have shown far more joint infections from injecting Legend than any of the other available intra-articular products. It's not common enough to stop using the product in the veterinary field, but it is enough that my vet doesn't like to do it.

My vet is going to look into the price of IRAP for me, as the office recently came up with a new package deal for it that includes all of the initial injections, blood collection, harvesting, sedatives for the horse, etc. There is no rush in doing it but if I'm going to do it, it should be done in the next 1-2 years.  In the meantime, I'm doing the oral joint supplement. Gracie will get long warm-ups at the walk (I foresee an argument in our future...the mare is always, "F walking! I WANNA GO!" She'll learn) and she will be getting an aggressive mustang roll on her front toes to ease breakover. My vet is awesome enough that we reviewed Gracie's lateral shot to see how the trim needs to be adjusted. (I said it before and I'm saying it again: it's nice to work with a vet that doesn't automatically recommend shoes for all the things. A lot of problems can be remedied by changing the trim) Gracie naturally trims her toes while being ridden, and I just back her up to where her feet indicate they need to be. I'm not taking more toe off, just doing a bigger roll. You get the same effect as you would with an eggbar shoe.

For the non-barefooters out there, this is what a mustang roll looks like:

Mustang roll in process. Photo from Barefoot for Soundness.
Finished roll on the same hoof. Ignore the white and pink lines; they were talking about flares in the hoof. I just want you to look at the toe. That's the infamous mustang roll. Photo also from Barefoot for Soundness.
Side shot of a mustang roll. Photo from The Horse's Hoof.
My vet said that therapeutic shoes like egg bars with wedges are often used to help ease breakover and lift the heels in cases like this, but Gracie's heels are perfect and rolling the toes should be enough. 

I need to get that new rasp already. 

The other part of the plan is basically frequent riding spread out through the week, which is something that I always try to do with my horses anyway. I like to spread out rest days when possible, especially if working more than 3 days a week. For now I am to give 1 gram of bute 30 minutes before riding so she is more willing to pick up the RF and is less likely to stumble. 

Will I be able to compete Gracie in endurance? Maybe. We'll see what happens with the management of the condition. We might be able to do LDs or maybe even 50s on flatter, more forgiving terrain than that provided by the Old Dominion rides if I can get her comfortable enough to where she doesn't need bute prior to riding. Bute is one of the many substances banned by the AERC and pretty much every other equestrian competitive organization, as you all know. I'll only do what she's comfortable doing. If all we can do is trail ride recreationally, that is perfectly fine too. And hey, we could still do stuff like competitive trail rides. I think Gracie would have a ball doing that too. 

You can go to the link here. Go watch it!! That horse is amazing! 
(And of course, this is at the highest level of competition for this sport, which is why there is so much speed work. You walk or trot at the lower levels.)


We shall see. :)


14 comments:

  1. I have had really good luck with pentosan and arthritis. My last horse had server arthritis in his lower back, specifically lumbar (L2 & L3), from an accident flipping over backwards with a farrier (this is another story and I won’t bore you with the details, but it was the last time this particular farrier will ever touch one of my horses, too little to late…). My horse had significant degenerative loss of cartilage over time between the vertebras. We did have to inject the vertebrae for relief, 6 months later the pain came back and we injected again. After this I put him on pentosan bi-weekly and I didn’t have to inject again for 18 months. This horse is now happily retired at 17 years old. Accident happened at age 9. I was able to ride and compete him happily for 4 years and then leased him to a young girl to compete in the lower levels to keep him having a job, until he said he couldn’t do it anymore. I find you just do the best for these horses and take them out of pain until they tell you they can’t do it anymore. Trust me, they will tell you… Definitely look into pentosan, I really like it. I am not sure how effective it is on ring bone, but it really helped my horse.

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    1. Thank you JWall!! This is fantastic to know! I will most definitely keep this in mind!

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  2. I'm just going to leave this here. Clearly make the decision that you think is best but at the very least I think this is an interesting read...
    http://www.doctorramey.com/intravenous-hyaluronan-legend/

    Gracie seems like such a good mare! Glad it's not euro and hopefully you can find anyway to manage this:)

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    1. Ok, I seriously laughed when reading Dr. Ramey's views on IV HA. Thanks for the link! *That* would be why my vet didn't mention IV Legend as an option! Good to know. The thought has been ditched and the post edited accordingly. Thank you for the info Mary!

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    2. I think a lot of people jump on the Legend bandwagon. I think Dr. Ramsey's points make a lot of sense (if your ever looking for another good read, he has an equally interesting article on Isoxuprine).

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  3. Ugh. We all need a break, I think. I'm SO glad it's not neuro, but sad it's ringbone. I agree, falling down is NOT NORMAL in horses.

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    1. I kept thinking of you and Ozzy. :(

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  4. Here is to Gracie overcoming her arthritis and ringbone. Does having it in one leg make her more prone to developing it in the LF?

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    1. I would think so, but I honestly didn't ask. I'll ask the vet when I e-mail her; she is supposed to send me the x-rays and I need to get more bute, so I'll talk to her then.

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  5. I'm glad you were so attentive, it sounds like you caught it early and have some good options. What a good Mom, Gracie is lucky to have you. And movement totally helps, having been around some creaky oldsters, I'm sure you'll both be glad for that! I'm not sure how much Bute you are giving, but just a caution, Major was on a very small amount for a couple weeks and got an ulcer. Probably depends on how sensitive your horse is, and you can probably feed something with it that can mitigate it. Just FYI.

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    1. Thank you irish!! And thank you for the tip re: ulcers and NSAIDs! I had the same issue with Lily last year when her vet at the time put her on a high dose of daily Previcox for a ligament strain. We had to discontinue it immediately. For Gracie the vet recommended 1 gram 30 minutes before riding only, which is about 4 days a week. So she's not getting it every day at the moment; I'm hoping to be able to slowly wean her off of the bute with the addition of the joint supplement (should arrive this week) and more frequent exercise spread throughout the week. We shall see!

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  6. Sorry to hear about the ring bone, but awesome that you caught it early and have some treatment options. I had a mare with a moderate case of arthritis for many years and the best thing for her was regular work, so I'm guessing you and Gracie have a lot of wonderful years still ahead:)

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  7. Aww that sucks, but I am glad it's not neurological! I'm glad you caught it early too. :)

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