Thursday, March 11, 2021

my experience with joint injections

I wrote yesterday about getting Charlie "up to date on his annual maintenance," and figured it might as well merit a dedicated post about what that actually means: Joint injections.

First, some background: Like many off track thoroughbreds, Charlie started receiving joint injections (typically some form of hyaluronic acid, more below) during his racing career. To my knowledge, he had his hocks and stifles done on the track.

the fields are so pretty at dusk!
My understanding is that these injections manage joint dysfunction (especially in cases of horses with arthritic changes) by increasing fluid viscosity and lubrication of the joint. (A joint being: any place in the body where two bones meet.)

Conventional wisdom suggests that once horses start this degree of intervention in joint care, it often commonly becomes a necessary "routine maintenance" for them to remain comfortable. Tho, my impression is that this depends on which joint you're treating.

amazing how quickly the ground has dried out this spring
Hocks, for instance, are commonly treated joints -- frequently you're injecting the joints between small bones within the larger structure, joints that have small gaps with minimal range of motion (Purdue has a nice diagram in this pdf) -- and Charlie's been on about a yearly schedule with them. I've also done his stifles once, and his front coffin joints too. 

Personally, the stifle injections didn't do much to address what I felt in Charlie's way of going -- whereas the hocks make a big difference. The coffin injections also made a big difference, and might be something we repeat in the future. Tho that treatment had less to do with 'routine maintenance' and was more circumstantial (drought year / very hard ground).

ugh i'm the absolute worst at scheduling, apparently. it's gorgeous out right now while charlie's stuck in his stall :(
I'm also not ruling out additional areas of treatment in the future: for instance, at some point we may take a closer look at Charlie's SI joint or neck. At present, however, the vet does not feel like there are any compelling presentations in the horse to justify further diagnostics. 

his field had been temporarily relocated onto grass too while a fence is repaired. sorry buddy, i kinda blew it for ya ugh
But --- it's important to note here: This is all based in my own personal approach to medical interventions in horses. Joint injections inherently carry enormous risk. Any time you open a joint capsule and introduce a foreign body (needle, drugs), you also risk introducing infection.

And joint infections are extremely serious. At their worst, they can threaten the long-term soundness or even the horse's life by creating inflammation and surface roughening within the joint itself -- an extremely painful and often permanent injury.  

marching in to meet his fate
I've also heard in conversations with trusted horse people (who, as we all know, are always FULL of opinions) that there's somewhat of a limit to how many times you can inject any single joint. 

That, after a certain point, you face diminishing returns and may find you're having to inject more and more often to keep the horse comfortable for work. Eventually, the horse may need to step down from the work when treatment is no longer sufficient or even humane.

drunk charlie gets scrub-a-dub-dubbed
So... Even tho joint injections are 'normal' and 'common,' they're not something to be taken lightly or without full deliberation of the associated risks. There are folks I respect immensely who avoid injections at all costs. 

Personally, I'm a little more comfortable with them (acknowledging my limited experience). The key is that: your mileage may vary and it's important to talk through options with your team if you're considering injections. 

the "sterile field" of instruments, drugs, scrubs etc... plus random unrelated grooming spray lol
I've owned Charlie for about 4.5 years at this point (how time flies!) and have used three different vets for his hock injections. It's interesting to me that each vet has a slightly different approach and practice. 

Differences can include the actual chemical substance injected (which has the most direct bearing on price and potential longevity of the injection), whether there's also an antibiotic included in the injection compound, and after-care as it relates to stall rest or turn out timing. 

i spy with my little eye, a feline interloper drawn as if by magnets toward said sterile field
For Charlie's most recent treatment, the primary injected drug (by a factor of about x10) was Hyvisc, a hyaluronate sodium compound. Secondary injection ingredients were MPA (an intra-articular (IA) corticosteroid), and amikacin (an antibiotic used as a preventative in this case).  

Obviously, the injection sites (inside and outside of each hock, TMT and DIT joints) were scrubbed aggressively and continuously for many minutes using a couple different antimicrobial solutions in preparation.  

each hock had two sites - making for somewhat precarious positioning 
The horse also received a number of drugs intravenously -- including sedation, obviously, to keep both horse and vet as safe as possible during this highly precise task. 

Other IV drugs included a shot of gentamicin (another antibiotic as added protection against infection) and bute for any pain relief. Charlie will get bute orally in his meals the next two days.

a rare moment of charlie standing on nearly all four legs.... he's the kinda drunk mess that likes to teeter and totter around on a tight rope. makes me hella nervous lol
This vet prefers to bandage the hocks post-injection with elastikon, and have the horse remain in stall rest for ~3 days. Previous vets have used Alushield as a liquid bandage over the injection sites and allowed Charlie to return to turnout immediately post-treatment. 

Personally, having seen Charlie do just fine with minimal post-treatment limitations... I tend to think that for this type of injection it's probably fine for them to go right back out again. However, I'm also a big believer in using the advice I buy from the professionals on my team. So if this current vet wants stall rest, that's exactly what we'll do.

She also recommends hand walking during the ~3 day stall rest period, then returning to turn out and resuming light work under saddle. Then, you're basically good to go! 

random shot of the beginning of this season's hoof woes. trying to get an early start this year!
Honestly, the most important part of post-care is observing the horse for any signs of septic joints. This would include a sudden change in the horse's behavior (lethargy, fever, loss of appetite), and extreme lameness and swelling. 

I've been told by a couple different vets that the lameness from joint infection is so obvious even Stevie Wonder could see it. In other words, you really don't need to guess if you're dealing with injection complications -- it's generally pretty clear and presents in the first day or two. Personally, I haven't experienced this myself -- it's just what I've been told. 

sad lonely pony prisoner
This whole process is fairly interesting to me -- tho (as always!) it's important to note I'm not a professional and Charlie is my first horse, and therefore the horse from which I learn the ins and outs of this type of treatment and care. I'll be curious in 5 or 10 or 15+ years, or with a future horse, when I look back on how I handled Charlie's care... Will I wish I had been more aggressive? More conservative? Or will Charlie be the model for how I approach all future creatures? Who knows!

Most of what I've learned about this type of maintenance has been learned through conversations with friends and barn mates and various professionals, or read on other blogs or forums or in articles etc. And so much of it.... kinda depends on who you ask, as seems true with so many aspects of horse care. 

So I'm curious -- have you ever done joint injections? Were your experiences similar to what I described? Or are there meaningful differences in drugs used or post-care treatment? Have you had to deal with a joint infection? Or maybe you avoid injections entirely, or in retrospect regret going down that route with a horse? Are there alternative treatments you turn to first? Or maybe a simple injection was a game changer for your horse in making them more comfortable and happy in the work? 



12 comments:

  1. Definitely do them for my kids! I try not to start too young if I can help it since I do think there's a limited amount of times you're going to see a benefit from it. And also that does depend on the joint you're working on. I've gotten a little more cautious about jumping to injections after Jamp foundered a few years ago. We're confident it was from the steroid. He'd been injected plenty of times in years prior, but our hypothesis is that in his old age, something had changed in his body and he couldn't handle the steroid any longer. It hasn't scared me off them entirely, Eros and Pammon both had their hocks done this year. Eros had his neck done too. And Pammon is about to have his SI done. But as they get older, I'll probably run a blood panel prior to injecting. I'm also really curious about the newer prp injections they're doing. It might be something I'd switch to as they get up in years rather than the steroid. We used the prp for Shiny's neck, and I do think it helped her. Though it didn't cure all of our problems. Nothing is ever a magic wand though!

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  2. As I mentioned yesterday, Cosmo just got a round of joint juice a couple weeks ago. Since I have owned him (7 years) I started doing his hocks 3-4 years ago. The first few times we did his SI along with his hocks and holy wow did I feel a difference right away. Those injections lasted a full year (last year I got 14 months of out them). However, with his unexpected increased workload from his leaser last year, we had to do his hocks a second time (and we skipped his SI and did his stifles last year) 3 weeks ago he was quite ouchy up front and the vet could see his head bob when his leg went forward, not so much when it hit the ground - so he explained how that usually indicates the joins on the front of the coffin are where it hurts. I asked him to flex his SI since that was almost 2 years since it's last injection and Cosmo did not like that. So we did his coffins and SI. I had never done his coffins but when the vet put the needle in he could see that joint fluid was practically water so it was very clear that it needed to be done. He also prescribed 3 days hand/tack walking and then return to normal work, with me feeling the full benefit in 5-10 days.

    I've only ridden Mo twice since his injections (weather, camping trip) but he felt GOOD. We jumped a couple little things and I asked for a short turn and Mo ROCKED back, made it way tighter than I meant, and POWERED forward to the little jump. I feel this was money well spent, and with his new workload (a bit less than last year) I am pretty sure these should last 12 months. We will have to do his hocks again, but hopefully, he'll get a year out of those too.

    I am also lucky that when he was younger, he was adequon (or legend - I don't remember) for general maintenance and I think that has paid off in the long run. He turns 25 in a few weeks and is still in full work, jumping 2xs a week (little stuff with his new leaser, and up to a 1m-1.05m with me). I know these help him, and I am not hesitant yet to keep them up. The dude still LOVES to jump any chance he gets.

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  3. I have been lucky enough that most of my horses haven't required joint injections. I did have my older mare on Legend injections (which are IV) which worked well for our purposes, as we do not have a regular equine vet in the area, so injecting joints and heading back home without vet support isn't the best idea! In Suzie's case, her knee was so full of arthritis we could not safely inject the joint itself - so Legend it was!

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  4. The one time I dealt with a joint injection was in a foal, and unfortunately he didn't make it because of that. So they're definitely a concern!

    I have done a few joint injections - mostly Amber's knee and her stifle after surgeries, but I since decided to do Adequan. She always seemed like she needed help more consistently than an injection every 6 months, and when it came down to it, it was actually cheaper to do that than having the vet come out and inject.

    Hopefully tho Sir Charles feels good after his maintenance!

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  5. I have always felt the stifle is too large of a joint to inject and personally prefer using PT like exercises to strengthen it and possible a shot of estrone to support the conditioning program.

    I did hock injections on Carlos and they were the worst timed vet procedure I ever did since I put him down like 3 months later.

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  6. Prior to moving to FL, I didn't have any experience with joint injections. I knew what they were, but I didn't explicitly know any horses who needed them. When Satin was due for injections, I started asking questions out of curiosity. In general, Satin's owner and my trainer agreed that you can expect to start around the age of 10 for competitive hunter/jumper horses and they're usually done annually so long as the horse is still in work. Blackjack just had his hocks and stifles done, Liberty is likely going to have or has had hers done recently, too. Blackjack also gets his whole back done as well because his conformation doesn't help him out in that regard.

    From my perspective, I'm kind of on the fence about them mostly because, as you mentioned, they aren't a permanent solution, and you have to stop at some point. And that point likely varies from horse to horse and discipline to discipline. They feel simultaneously a reactive treatment while also being preventative maintenance. Idk, I probably just don't have enough experience to fully wrap my head around this.

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  7. As a kid/junior I never had a horse get a joint injected or saw another horse at the barn get one injected. I don't even think we gave a joint supplement, just a multivitamin. So as an adult I was kind of surprised at the frequency I saw it done.

    My first experience with steroid injections was Stampede's back. He didn't have any issues (except being allergic to their scrub lol) but those injections just don't last long and pretty much you are lucky to get much result after you do it a couple times. His second injection only lasted a few months. Thankfully after that I met a great vet who taught me how to rehab him properly and we got him going again for a few years. During that time I did get his hocks done once - the rest of a horse's body takes a lot more wear when they are compensating for a back issue. After that injection he was on equioxx until he retired as well as monthly Adequan.

    I had Phoenix's hocks injected once because hey he was in his mid 20's and he needs it right? It was the worst. One hock swelled up with inflammation (no infection) that took months to resolve. By the time he was back to work I felt no difference anyways. He is still on monthly Adequan these days but I would never inject a joint on him again unless I had too. At my boarding barn I've now seen two other horses react this way to a joint injection, one by the same vet I used and one by another vet practice all together, and one of the two horses ended up with a permanent softball off his hock.

    Ernie had annual hock injections at his prior barn because that's just what they do for all horses. Totally not my thing if they don't need it. He had flexions and x-rays when I bought him and his hocks were fine. So he's probably nearing two years since he had them done now. His right hind ankle has a healed sesamoid fracture that I opted to do a PRP injection on in December and I'm so happy with that. I think I would do PRP for his hocks should the need arise.

    I should mention that Stampede went on steroids for a skin issue and that's what caused his EHV5 to progress more rapidly so I clearly have a bias against steroid use in horses at this point. I see it done and many horses are just fine but the risk is tough for me to swallow when there are other options.

    Sorry for the novel lol

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  8. Opinions about joint injections vary hugely even among veterinarians. At a CE conference I went to a few years ago there was a 50 minute table topic about joint injections and it seemed like everyone who spoke up had a different way of doing things, or what they put in their injections.

    I always describe a joint infection to my clients as, "it will look like your horse has a broken leg" because it is that severe of a lameness, even on bute.

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  9. I'm totally open to the idea of joint injections but am a firm believer that they're not a fix-all for a horse that is allowed to go poorly. *Disclaimer this is not a direct comment on anyone in blogland or that I know in person - it's just my personal thoughts. For example, I see a ton of people jumping to inject an SI when I've had many conversations with vets and professional trainers that believe you can *likely* avoid an SI injection by working the horse correctly and slowly to build up necessary muscle and strength.

    Goose turns 17 next week, and while he feels great he does get a bit more shuffly at times and loses his hind end. I'm considering having him evaluated for potential monthly maintenance (Adequan, etc) or injections. Before I do that though, I'm getting him back to work with tons of correct work to see how much that helps what I'm feeling before I jump to vets and maintenance.

    In short (?lol not a short comment, sorry!) there are many roads to Rome, and I think horse owners need to determine what's best for their horses. Particularly athletic sport horses who do a heck of a lot more than my land hippo does!

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  10. I've had Phantom's hocks injected annually since she was about 10. For the first years it made a big difference, the last couple of times not so much for the left side. I've stepped her workload down considerably and she gets Previcox when she's going to be ridden these days and I don't know if I will get them done again.

    I always thought that an infection due to the injection would show up in a couple of days, but I was told a few years ago by the vet that it could be a week or so (takes time for the bacteria to grow?) before I would notice anything. So don't think you are out of the woods if nothing happens in the first couple of days!

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  11. I have not done injections. However, I wonder if Carmen will need them at some point.

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  12. I'm very pro-joint infections, as long as they're recommended and driven by a vet I trust. Have seen a huge difference in my horses, and think it's one piece of the longterm soundness puzzle.

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