LAMENESS DIAGNOSES: WHY SO MANY TOOLS?

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LAMENESS DIAGNOSES WHY SO MANY TOOLS?
ANTONIO M. CRUZ DVM, MVM, MSc, DrMedVet, Dipl
ACVS, Dipl ECVS Board Certified Specialist in
Large Animal Surgery American/European College of
Veterinary Surgeons Paton and Martin Veterinary
Services Aldergrove, BC
www.pmvetservices.com
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DISCLAIMER

• THE MATERIALS CONTAINED IN THIS PRESENTATION ARE
  PROTECTED BY COPYWRIGHT LAWS. PLEASE DO NOT
  DOWNLOAD ANY OF IT FOR OTHER PURPOSES THAN
  PERSONAL USE.

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WHO AM I?
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My work as a University Prof.
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Lameness Investigation

• Methodic
• Not rushed
• Set realistic expectations
• May take several days

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Our Most Important Tool
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Process

• Adequate history of problem Listen!!
• Ask relevant questions
• Observe!!
• From a distance
• Horse posture\attitude
• Conformation
• Muscle development

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EXQUISITE KNOWLEDGE OF ANATOMY AND FUNCTION
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CONFORMATION
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CONFORMATION
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FOOT / DIGIT
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Hunters bump
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PALPATION

• BACK
• LEGS
• HEAD AND NECK
• MOUTH
• HOOF TESTERS
• FOR SORENESS, SWELLINGS, HEAT

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PHYSICAL EXAM

• Range of motion (ROM)
• Regional
• Active range of motion voluntary
• Lateral, flexion
• Passive range of motion under sedation or GA
• Active Assisted ROM Stimulate to move
• Wither elevation, trunk elevation, spinal
  reflexes
• Soft Tissue palpation Sensitivity
• Skin, fascia, muscle

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DYNAMIC EXAM
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Horses gait
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Appreciate movement
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NEUROLOGICAL OR LAME
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FLEXION (STRESS) TESTS
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MYTHS

• There is a characteristic gait for each lameness
  False
• Horses always compensate the same way False
• Nerve blocks should only be done after imaging
  False

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FACTS

• There is no magic wand
• You ALWAYS need to eliminate the lameness to
  identify its origin by nerve or joint blocks
• You CANNOT ALWAYS identify the origin of a
  lameness
• Horses compensate in many different ways

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FACTS

• Lameness evaluation is an art that requires
  accurate work and the examiners brain CANNOT be
  substituted by computers or imaging.
• Any diagnostic tool is only as good as the person
  using it.
• Indiscriminate use of diagnostic imaging tools
  will cloud the picture and confuse you, besides
  costing you unnecessary expense.
• A horse is not your car!

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NERVE/JOINT BLOCKSBLOCK ANAESTHESIA

• They are the ONLY way to connect the clinical and
  imaging findings to the REAL problem so it can be
  identified
• By abolishing the pain we are confirming the
  origin
• They isolate a segment or joint
• They are not 100 - Need interpretation

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A note about blocking the foot
Today the diagnosis of heel pain remains
elusive. However with the advent of MRI we are
learning the group of lesions that in the past
may have been considered navicular disease or
syndrome. It is important to recognize therefore
that not all heel pain means navicular disease
and that only after an appropriate and extensive
diagnostic work-up which may require extensive
blocking and diagnostic imaging such as MRI the
diagnosis of navicular disease can be made.
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HEEL PAIN SYNDROME

• Defined as a lameness that responds to a palmar
  digital nerve block.
• It may include diagnosis such as
• Navicular disease/syndrome
• DJD of coffin joint
• Navicular bursitis
• DDF tendonitis
• Coffin join collateral ligament desmitis
• Sole bruises
• Sheared heels

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Summary
Digital palmar Coffin joint block Navicular bursa block
Podotrochlea (Bursa, ligs., bone)
Sole, Coffin, DDF, Dig cushion, Impar lig. -
Sole, Paster, DDF, Sesamoid. Susp ligs. - -
Podotrochlea (Bursa, ligs.) -
Proximal lameness -
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EQUINE FOOT DIAGNOSTIC NERVE BLOCKS
Abaxial sesamoid block Palmar Digital n.
block
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Palmar digital (PD) nerve block

• VOLUME
• 1.5 mls
• MEANING
• 5 minutes
• 15 minutes
• 30 minutes

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Abaxial sesamoid block
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Navicular Bone

• Deep digital flexor tendon runs over it
• Insertion of ligaments
• Forms part of coffin joint
• Covered by hyaline cartilage on dorsal (coffin)
  side and by fibrocartilage on palmar (Nav. Bursa)
  side

Deep Digital Flexor Tendon
Navicular Bone
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Coffin Joint
Made up of coffin bone, pastern bone and
navicular bone Minimal motion forward and
backward
Second phalanx pastern
Coffin Bone
Navicular Bone
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EQUINE FOOTDIAGNOSTIC SYNOVIAL ANALGESIA

• COFFIN JOINT
• Joint, navicular bone, distal aspect of DDF,
  impar ligament, sole, palmar processes of the
  coffin bone,
• NAVICULAR BURSA

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COFFIN JOINT ANAESTHESIA

• PREVIOUS RESULTS
• 20 of horses with navicular pain did not
  response to coffin joint anest.
• 80 of horses without radiologic abnormalities
  of NB but with positive response to coffin joint
  were positive on scintigrafia of the podotrochlea
  
• 70 of horse with NB abnormalities on MRI had a
  positive response to coffin joint anaesthesia.
• 90 of horses with lesions on DDF detected by
  MRI responded to coffin joint anaesthesia within
  5 minutes.
• 17 of horses with lesions on DDF detected by
  MRI responded to Nbursa block
• 90 of horses with positive response to coffin
  joint anaest and N Bursa had positive
  scintigrafic findings on the podotrochlea.

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Navicular Bursa Block

• More specific than coffin joint
• Evaluate at 5, 15, 30 minutes
• Positive response indicates podotrochlea
  pathology
• May desensitize DDF insertion and heel
• Results (59 horses Dyson y col.)
• 60 of horses had radiographic abnormalities and
  all of them responded to N bursa block
• 70 of horses with abnormalities of the NB found
  on MRI showed a positive response to blocking of
  the bursa.
• 12 without response to coffin joint or bursa
  had normal scintigraphic findings.
• Lack of response to coffin joint anesthesia and
  bursa eliminates almost entirely the diagnosis of
  navicular disease.

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WHATS NEXT?

• AFTER a limited anatomical region has been
  identified, imaging should proceed

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IMAGING TOOLS

• ANATOMICAL
• Radiographs (for bone / joints)
• Ultrasound (for soft tissue, tendons, ligaments)
• MRI (for hard and soft tissues)
• ARTHROSCOPY
• FUNCTIONAL
• Scintigraphy bone scan
• Thermography
• MRI

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X-rays (joints)
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X-rays (Cysts)
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X-rays (chips)
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Why X-rays are the gold standard
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Contrast Enhancement
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ULTRASOUND TENDON SHEATH
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ULTRASOUND LIGAMENT
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ULTRASOUND JOINT
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ULTRASOUND STIFLE
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ULTRASOUND BONE CYST
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BONE SCAN
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BONE SCAN
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MRI - STANDING
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MRI-Anaesthetized
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ANATOMY
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Our Most Important Tool
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THANK YOU!
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