Sunday, December 22, 2013

In which Dixie gets three new legs for Christmas

This is a hard post for me to write.  Most of what I do is either a) clearly stupid or b) uncontroversial within my discipline, but joint injections are a little more contentious.

Like most endurance riders, I'm pretty deeply paranoid and I plan out every option I can think of ahead of time.  I know my "hard limits" for treating most equine health problems, and I've got a bunch of little checklists and flowcharts constantly running in my head. Earlier this week, I pieced together some possible symptoms I'd been seeing this fall and decided that Dixie's hocks were maybe sore.
  • Dixie's been reluctant to go downhill a few times - alone in the dark at VC, in the slippery mud at Briones two weeks ago, and intermittently on the local trails for the last few months.
  • She's started picking her way downhill, zigzagging across the trail instead of walking straight down. 
  • She (infuriatingly) refused to hold her back feet up long enough for me to trim them earlier this week.
Additionally, she'll be 12 next year, she's gaited, and she was padded in her misspent youth - that ridiculous action cannot be easy on baby joints.  Any one of the above symptoms could be Mare Attitude or random variation, but all three points in such a short period of time set off an internal alarm.

So I called the vet.  My usual guy doesn't do joint injections in the field*, so he recommended I haul out to Pioneer Equine in the Central Valley. Friday we headed over for a workup. 

Dr. Lefkowitz got our history and watched D trot out straight and in circles on a hard surface and in a softer arena.  She palpated all her joints, flexed her and had her trotted out again, went at her with the hoof testers, and looked at the rads I got last month.  (I was rather proud that D didn't even wiggle an ear for the hoof testers.)  The vet thought there were some arthritic changes in her front left fetlock, which I hadn't expected but wasn't surprised by.  They blocked her LF and lunged her again and she was much improved, but still not really moving under herself like she should and has in the past.

Twitched for the block.
So she recommended injecting Dixie's hocks and her fetlock.  We could've done more rads, but like flex tests, they're not dispositive.  (That's a real word, but it's also a legal term of art - probative evidence means something probably happened, and dispositive evidence decides the issue.  "You're my husband so you're the father of my child" is probative, but a DNA test on the baby is dispositive.) Anyway, sometimes you can't see the changes on x-rays, and sometimes a horse flexes horribly but stays sound or vice versa, so it's not always easy to say for sure what's going on in those joints.

"Have you ever looked at a dollar bill... on xylazine, maaaan?"
Good girl.

We headed back into the exam room, sedated Dixie (she's a very cheap drunk), and did the injections. The tech (who was great, but I don't remember her name and it's not written on my paperwork) Betadine scrubbed the everloving shit out of D's joints* while the vet prepped the injections.

*Of course, in the two days between deciding that Something Was Going On and actually seeing the vet, I researched the shit out of equine joint problems.  I am in no way a vet, but I can slog through google results with the best of 'em.  The major risk with joint injections is infection, which is rare but Very Bad Indeed.  Current best practices that I read about were to: scrub really well, don't clip or shave, use the smallest gauge needle possible, and pop the needle in and let the joint fluid drip out to clear any debris in the needle - Pioneer did all that.  They also bandaged her ankle (but not her hocks - they're so hard to wrap, and they're higher up so they're probably not going to get foreign matter in them).

Anyway, they loaded her up with some IV bute, wrote some really nice case notes/discharge instructions, took a vast but not unexpected amount of money from me, and sent us on our way.

I kept D inside for the rest of the day and unwrapped her bandage on Saturday.  She's back outside, but on "stall rest" with 15 minutes of handwalking til Monday or Tuesday, then I'll slowly resume our regular schedule.  None of her joints are warm or puffy, so I think we're in the clear.  And she's definitely moving better (straight, free action, no hesitation) downhill already - I don't know if it's just the bute or if her hocks are feeling better from the shots already, but yeah, there was something going on.

The real question isn't "will you treat something that's treatable," it's "what's next?" And for us, it's more of the same.  If her fetlock bothers her again too soon, or if it's been a couple years of biennial hock injections and they're not pain-free and finished fusing, we'll try to find some other sport that we both enjoy this much.  But Dixie really does enjoy endurance rides, and many successful high-mileage horses go through this (even if not everybody confesses it on their blog!), so yeah, I'll give her a chance to keep doing endurance.

It's basically the same thing I said after her tendon pull in 2011 - if she re-injures herself in the same spot, I'll reconsider our sport, but I'm going to give her a chance again.  How soon is "too soon" w/r/t the fetlock?  I'm not sure; I kinda hate the thought of needles in joint capsules.  But shit, if I had a bum joint, I'd probably get cortisone shots if they let me keep doing what I love to do.

After paying the vet bill, I had enough money left to buy Dixie a big candy cane.  And I'd already bought my own horse-related presents - memberships to NASTR, CALSTAR, and WWHA for 2014, whee! Merry Christmas, if that's your thing, and happy solstice to everyone in the Northern Hemisphere!  We're over the worst of it and the sun is coming back - whew!


  1. I like your comment on "But shit, if I had a bum joint, I'd probably get cortisone shots if they let me keep doing what I love to do." Because that is exactly what I do! Haha! I get back injections so I can keep enjoying my life (it isn't just a matter of riding).

    I don't know how I feel about joint injections. Because I have not ever faced that decision with a horse myself. I think it is very specfic to the horse and how much they love the sport they need the injections to keep doing. Since we all know how much Dixie loves her job, I would have made the same call you did. Down the road, I would also reevaluate if need be, things change. Risks change, benefits change. As long as you are open to reevaluating and changing sports if need be, I can't fault you at all.

    Your doin' it right!

    I think some of the bad rap joint injections get, is from people who just shoot up their horses to keep making money with a horse who isn't happy anymore, or someone who just keeps giving them blindly without further thought to other options.

    But I also cringe thinking about needles in joints! I have to really not think about that part when I am getting my back done.

    I'm glad Dixie is feeling better already! And I know it's a little mean, but I love drunk horses! Haha!

  2. I'm glad all went well and I hope it stays that way. While going downhill today, my DTV (Dog Transport Vehicle) decided to tell me its brakes are shot, so I guess my "horse-equivalent" will be getting new brakes for Christmas. :(
    Happy Solstice and Merry Christmas - may it be a mild winter and an early spring!

  3. I honestly am a little baffled by strongly anti-joint injection sentiments. Yes, it's a medical procedure and can go awry but IME the intensity of reaction is way out of proportion to the risk involved, and letting a horse continue to be ouchy without intervening is...not unproblematic.

    Tucker's hocks have been done once, in 2012, and I'll have the vet out prior to the start of the 2014 season to reevaluate. I did a lot of thinking about it and drew some lines in the sand for myself when we did those first injections. Basically, I'm comfortable with injecting to maintain comfort and performance; I would not be comfortable with injecting to increase performance. Mileage, of course, may vary.

  4. Her mane. It's so long!!

    And I'm really happy you posted and shared this. You're doing so right by Dixie. Your logic, research, and care for your horse as a result are incredible and inspiring. Q has shown some weirdness with handling her hind feet of late, too, but I have a few behavioral issues to rule out first before moving the same direction you have. Thanks for sharing. It gives me some confidence to move in that same direction if behavior things don't resolve.

  5. I think people judge joint injections too harshly. I think they are often overdone and used as a crutch, but I also think they can be an invaluable piece of a program such as in your example. No tarring and feathering from me for this post!

  6. Ugh, I know that stacked horses blow their hocks out very very early, hopefully she wasn't that way long enough to do lasting damage.

    Did any of the vets have anything to say about IM Adequan shots? That's what Gene is on, on a 5-week rotation, simply because he has too many stiff joints to pinpoint directly. While he is still arthritic, his range of motion has not diminished but actually has improved a little over the years (he's been on them 3-4 years). It's a lot less nerve-wracking than in the joint and is something we administer ourselves. However it's definitely not as effective, I believe.

    I also knew first-hand of a horse with an infected hock due to a shot in an improperly sanitized joint administered in the barn. The horse was almost put down and it's a miracle she can still be ridden after her long recovery. Nothing but respect for your vet who won't do them.

    Glad to hear that everything's going well and you're seeing improvement!

  7. I love your blog, and I learned a new word, which makes me love you more.

    Also - I wanted to get a bit candy cane for Caspian... Can they eat them safely?

    You're so in tune with your horse you picked up on pain cues before she was even doing anything crazy obvious. I think you're safe continuing to do endurance with her - you and she are tight enough that I think you'll hear her telling you when she's not having fun anymore.

  8. I have long been on-the-fence about joint injections, but so far the 2 horses I have had done are doing exceptionally well. In Moon's case, I wished I would have broke down a couple of years ago and had them done and in The Big Bay's case, chances are, he is never going to be real sound without them. It was a last ditch effort for that horse, but it seems to be working out well for him.

    Out of curiosity, did the inject Dixie's hocks with both HA and Cortizone this time or just Cortizone to speed along the fusing?

  9. I think it boils down to what Hannah said (because she said it first in the comments): "I'm comfortable with injecting to maintain comfort and performance" but not to improve performance. As long as D wants to play the endurance game, I'll help her out, but I wouldn't feel right injecting her to get a little extra oomph.

    Sarah - the last time I looked at the literature, IM Adequan wasn't as effective as actual joint injections, but I'm going to look at it again now that I've done joints. I take oral glucosamine and I think I feel a difference (enough to keep spending $30 a bottle on it or whatever), so it does help in some situations, and I'd be happier doing IM adequan than any kind of joint injections :) And YES, ugh, infections.

    BEC - she went with Kenolog/Hyvsic in the fetlock and Depomedrol/Hyualovet in the hocks, so yes - ha/steroids in both, but different products in each. The fetlock got a more expensive, higher molecular weight, more effective on high-motion joints combo - one fetlock cost almost as much as two hocks, fwiw.

  10. I had Mimi's hocks done about 6 years ago and it was the best performance and comfort-related decision I've made. I ended up having to do once hock twice and one hock four times, and it took about two years for them to fuse, but she's sound and happy.

  11. Good post! And interesting comments from other readers.
    I think Dixie is a very lucky horse to get these not-so-cheap injections, and I wouldn't hesitate if I were in the same situation

  12. What Hannah said. That's exactly my sentiment on this subject. I don't have a problem with a treatment/procedure as long as the main goal is to keep the horse comfortable, whether at work or at rest. My own mare has very upright hind limb conformation and has some minor effusion in her hocks at 7 years of age. Not enough to warrant joint injections yet per my vet, but enough to have her on a heavier duty joint supplement. So far so good, but I know it's just a matter of time before we're facing this decision too. Thank you for sharing your experience. I've seen some pretty dramatic changes for the better in other horses who have received joint injections, and I hope Dixie is the same!

    Merry Christmas to you too and happy solstice!

  13. Joint injections *sound* more ooky than they are (although that moment when the needle punctures the joint capsule...>shiver<...there's nothing quite like THAT sensation, no matter how much numbing agent they put in the juice). I definitely support cortisone whenever, wherever, for the reasons you stated.

    I just wish they'd do HA on human hips. Sigh.

    Good call, Funder. I know that you know it, but sometimes it's good to see other people saying it. So, here ya go: Good call.

  14. IM Adequan is really great... It gave me the ability to avoid hock injections for Gogo for 3 years. She went from pulling rails at every event to sailing around smoothly. It's worth looking into. I also use a generic injectable glucosamine that I have had GREAT luck with - similar success to what I had with Adequan at a sixteenth of the price. I use that preventatively now on the ones who are working hard. I also feed Cosequin - pretty much every other feed-thru is useless but I've seen Cosequin improve every horse I've had it on that needed a little help!

  15. I've been injecting my mare's hocks for four years, and we're about to back off from it now, as the fusing has progressed. The first year was a nine month cycle, and then it was just yearly--she was nine and is now thirteen. She's a reiner in moderate dressage-type schooling. Very low-set hocks.

    She generally tells me when it's time to inject, just from the stiffness in her action. Vet does it at our barn, but they're very meticulous and careful about it. Not had any problems to date.

  16. Thirding Hannah's comment. I looked seriously at the possibility of injections for Fetti and was totally prepared to have her hocks injected earlier this year, but so far the Cosequin seems to be sufficient (or it's the extra work, whatever, she's improved what I was worried about and that's good enough for me). She's 17, and I know somewhere down the road it's likely to happen for us. I'll keep her comfortable, whatever that takes, and hopefully that means we can keep doing LDs a while; if not then I hope she settles into life as a trail pony instead.

    I hope the injections keep working awhile for Dixie, and that they don't need to be done too often. And wooooooo, solstice! Rejoice rejoice rejoice.

  17. Excellent post, and I think you're doing right by Dixie, which is first and foremost. We get older, we need some help doing the stuff we love, until it's too hard to do that thing anymore. Horses, people, we're the same in that respect. And happy solstice, we made it through the darkness into light...

  18. You can sure find some nightmare stories about joint injections when you go poking around, but I'll tell you this...when my first mare got so she was hardly using her hocks anymore, we had her joints done and it was amazing! The difference was such that there was no doubt in my mind we'd done the right thing. It made a definitely difference in my girl's quality of life.

  19. The immediate improvement you saw is often due to local anesthetic that is used during the injection. You may see that wear off and see her become sore again for a bit. It can take 3-4 weeks for the injections to become fully effective.

    I found this post to be very interesting because I have a 5 yo TWH/SSH mare who is built very similarly to Dixie. She has never been stacked or shown, but was injured by another horse two years ago. She has been sound, but I am recently having trouble picking up her back feet again and seeing reluctance to go down hills. Her troubles are in her back and stifle though.

    I hope the injections work well for Dixie and you can both continue to do what you love.

  20. I've done joint injections on several horses, all around Dixie's age, and all very active. For each of them, it made a huge difference in how the felt and carried themselves. I don't particularly like doing it, but I really do feel like our equine partners are athletes, and we need to take care of them as such.

    Something else you might look into is injectable glucosamine. You can do it yourself, it's very reasonable (much much cheaper than Adequan or Legend) and I've seen it make a difference. Certainly I'd go the injectable route before doing a feed-through supplement. It may help lengthen the time between injections considerably.

    I hope Dixie enjoyed her candy cane as much as the drugs! ;)

  21. What surprises me is that Dixie managed to hit 12 without needing injections before now! Not because of how you treat her, but with her being stacked and shod so horribly when you got her. (I was actually reading your blog way back then when you first talked about her!) I think it's a token to how you've managed her health all these years that only now is she needing injections. :)

  22. I hope the injections keep Dixie motoring for a few more miles! Why not do it if it works for you? You researched it, went to a respectable (hopefully! lol) clinic...etc. etc. I think, like with all horse "issues" so many people do stuff for monetary gain or just to compete and push the animal without considering all the angles. I would def. consider it for Spencer in the coming years...

  23. I have a good source for human grade hyaluronic acid that is given orally. It's intended to support the pentosan injections Val gets monthly, and seems to be working. Very affordable too. Let me know if you want more info...

    Hope your holidays are fab, and best wishes for a happy, healthy, prosperous New Year!! (((♡♡♡)))

  24. Thanks for writing about something that was hard for you to write about:) It sounds like you made a decision based on the information you could find, and I think that is all any of us can do. I tend to be anti-medical stuff, especially for myself, but even I would never rule out something that could make my horse more comfortable. After all, he works the hardest out of the two of us!:) I hope that the injections do help Dixie feel more like herself and that you both have many thousands of miles of happy trails ahead!

  25. You inspired me to join PNER. :)

  26. Injecting hocks to keep a horse sound and happy? Great idea, I'm glad the medicine is out there, and really happy for you and Dixie. I think the howling over injecting joints comes from using, say, adequan to keep a three-year-old sliding through the futurities....It's a case of damning the cure instead of the cause.

  27. Sera gets her hocks injected. When we first looked at having it done ... While I KNOW others do it and it is a routine thing in the horse world and it never bothered me to hear about it before....when it was MY horse I was HUGELY bummed out about it. Like that my riding and sport did this to her...and was it fair to her? Totally, totally bummed out. Decided I did not have enough $$ to take on another horse and retire her to an occasional riding horse and was assured horses are happier with jobs (tho I dunno if this is really true haha)... So we are both happy and she is still my fabulous red head. But now, I can totally relate if anyone balks or does not want to do this. :)

  28. Hope you have good luck with this. You mentioned "many successful high-mileage horses go through this (even if not everybody confesses it on their blog!)" and wanted to say that neither Chief nor Bo have EVER had a single joint injected. Since you posted this blog I have had people ask me and hope that others aren't just assuming that all high mileage horses require joint injections, because they don't. If my horses were to need joint injections, I would have it done and retire them from endurance, like I did with my first endurance horse Weaver. That is how I feel about MY horses and I have come to feel more strongly about that as the years go by. I am totally okay with other people doing what they feel is best for their own horses. A good % of horses in the point standings are getting joint injections, it is a fairly common procedure. I just wanted to share how I feel about it.

    1. Just because you haven't injected their joints doesn't mean they're not going through some pain that you don't realize... when I had my Holsteiner mare done, she was sound, just stopping at fences and her rads were a little questionable. After her hocks were done, she was a BRAND NEW horse, and I had to ask myself "wow, how long had I been making her truck along in some sort of low-grade pain and had no idea?"
      Honestly I think it is more cruel to be anti-injection and never consider helping the horse out when they need it.


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