We often hear the term “team approach” regarding many aspects of life, especially health care. The same is true of equine health care. That team could include the primary veterinarian, veterinary specialists, owner, trainer, barn manager, farrier, acupuncturist, physical therapist and others. Since degenerative joint disease (DJD) or osteoarthritis (OA) are lifetime challenges for many horses, the “team approach” to managing these horses is especially critical over the long term.
We asked a “team” at the University of Pennsylvania’s New Bolton Center to chat with us about a “team approach” to manging a horse with DJD. There are great tips in here for any member of such a team.
Meet the Team Members
Kayla Ortved, DVM, PhD, DACVS, DACVSMR (American College of Veterinary Medicine and Rehabilitation), is the Jacques Jenny Endowed Term Chair of Orthopedic Surgery at the University of Pennsylvania’s New Bolton Center. She is an assistant professor of Large Animal Surgery at the University of Pennsylvania School of Veterinary Medicine. Kara Brown, VMD, DACVSMR, is a lecturer of Equine Sports Medicine and Rehabilitation at the University of Pennsylvania, New Bolton Center. Patrick Reilly, Grad.Dip.ELR, joined New Bolton Center as chief of Farrier Services and director of the Applied Polymer Research Laboratory in 2006. He received his graduate diploma in Equine Locomotor Research at the Royal Veterinary College in 2020.
Ortved said a lot of these cases are managed by a single person, the attending veterinarian. But, there are a lot of recalcitrant cases that don’t respond in the way the veterinarian expects.
“As veterinarians, we do a lot of joint medications and other medications,” she said. “But we might need adjunctive therapies, like a farrier assisting with shoeing.”
Ortved noted that the equine veterinary industry has a poor history of rehabilitation using physical therapy. She explains, “That’s a major arm of human care.”
She said that if a horse isn’t on the right track of recovery, veterinarians should reach out to others. “It’s important to the horse’s comfort,” she said. “Physical therapy can help the horse become stronger or improve proprioception.”
She also advised more advanced imaging on cases that aren’t responding to treatment. The horse might need surgery.
“Some horses have joints with OA that have reached the limit to treat medically,” Ortved noted. “Or there might be joints that surgeons can help from the start to fix a fracture or remove a chip or even perform arthrodesis.”
Adding Rehab When Managing DJD
Rehabilitation in equine veterinary medicine has made huge advances in the last few years. “Rehabbing a horse with DJD is a three-prong approach,” said Brown. First, the veterinarian has to assess the damage and manage the pain. “You are treating from a focal standpoint,” she explained.
That treatment might include systemic NSAIDs, joint injections, cryotherapy and nerve stimulation. “Once we treat the pain there is so much more we can do,” she stated. Horses have to return to function, Brown explained. She pointed to the need to get up and down and walk to get food and water. “How do we get that function back?” she asked. While the team focuses on the area of damage, she said they also address the rest of the horse’s overall fitness and strength.
“If surgery requires stall rest, how do we maintain musculature?” Brown asked. She said that ways to help a horse while at rest are well-defined in the literature. That might include dynamic mobilization, Therabands, tucks, walking over poles … exercises that focus on core strength.
Farrier on Call
Reilly said that the comfort level of the horse reflects how a farrier manages the foot. “It’s all trial and error; it’s not an exact science,” he said. “I need, as a farrier, a diagnosis and to know what we are trying to protect,” he said. “That makes the difference in how we shoe.”
Reilly said a study in England showed that only 6% of farriers who saw a lame horse recommended that the horse see a veterinarian. He said that if farriers notice early arthritis in how horses flex or move, they should work with the owners and veterinarians on those cases. “It should be easier,” he said of the teamwork.
“Keep in mind that great shoeing jobs become terrible shoeing jobs in eight weeks,” stated Reilly. “All the work we do becomes obsolete. A great-looking alignment on the day of shoeing looks bad in six weeks!”
He said that all of his shoeing is based on a veterinarian’s diagnostics.
Case Study About Managing DJD
We posed a case for this team to figuratively work on together: a horse that has arthritic fetlocks front and back but is more severely affected in the front.
Ortved said the fetlock in all athletes is a high-motion joint that is highly loaded. “You get wear and tear,” she said. She said these types of horses are hard to treat because they have such a heavy dependence on the joint.
“In the early stages, you bolster the health of the joint with intra-articular medicines,” she said. “We use regenerative medicines that have a more protective effect, such as blood-derived treatments and stem cells. In cases that have moderate intra-articular inflammation, I might use short-acting corticosteroids. HA is an additive that vets like for lubricant. Then there are the polyacrylamide hydrogels. There are a lot of things you can use IA.
“I use Adequan [i.m. (polysulfated glycosaminoglycan)] as an adjunctive therapy, especially in the early stages,” she added.
If there is fetlock osteoarthritis and a bone chip, she said some horses can benefit from surgery. “If I do arthroscopy, I can see the damage a chip has caused,” she noted.
Ortved said that sesamoid fractures don’t heal well, so it is important to remove the fragment(s). “With any fracture, we stabilize it to limit OA,” she said.
“If we see a horse with severe OA and it is severely lame and its quality of life is compromised, but the owner doesn’t want to put the horse down, I have had success fusing the fetlock,” said Ortved. “It is complex, and the horse ends up with a ‘peg-leg’ movement following surgery, but they are comfortable.”
Reilly said that for a farrier in this type of case, “I’m a mechanic, and I try to change the force up the leg. Distal to the fetlock, I can use pads. But by the time you get to the fetlock, you can’t influence concussion above that.”
He said he works with the attending veterinarian to trim, add a wedge or make a shoe that is wider on one side than the other to try and change loading. “I cite human research on this because we are way behind” in researching this type of shoeing, he explained. “You have to remember that each horse is different, each foot is different, and they handle pain differently.”
Brown said that depending on the history of the horse and communications with the primary veterinarian, signalment is the No. 1 thing she looks for from the horse. She wants to know what this horse was doing for a living and what it is going to do.
Importance of Exercise
“Exercise is important to maintain comfort,” she stated. “That’s why older OA horses don’t do well with stall rest.”
She said focal pain management with therapies (such as cryotherapy) that do decrease pain and inflammation are important. “We want to decrease the inflammatory biomarkers as well with systemic therapies,” she added.
In rehab, she will focus on things such as passive range of motion, synovial fluid nutrition, maintaining movement, therapeutic ultrasound to improve elasticity of collagen, underwater treadmill, walking over poles/cavaletti poles, dynamic mobilization and therapeutic bands.
Focusing on nutrition for healing is important, said Brown. “It is easy for some horses to gain weight during this time,” she said. “We don’t want more weight on the limbs, and fat can add to metabolic issues. And we make sure owners monitor weight when the horse goes home.”
Take-Home Message About Managing DJD
Ortved noted, “I’m very reliant on Pat for mechanical support. My knowledge and [areas of] expertise [are] joint and cartilage biology, regenerative medicine and pathophysiology of osteoarthritis. You don’t have to know everything about everything.”
Brown stressed that the attending veterinarian and the owner are important parts of the team once the horse is sent home. “The owner can pick up on subtle signs and let us know and the referring vet who sees the horse,” she said.
Ortved agreed, saying, “There are three of us on this team, but the person at the top of any team is the referring vet.”
Dr. Kyla Ortved is a paid consultant of American Regent, Inc. PP-AI-US-0851