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All you need to know about why Proximal Suspensory Desmitis (PSD) of the hind legs of a horse does not require neurectomy and fasciotomy surgery

"Problems cannot be solved at the same level of consciousness that created them."
– Albert Einstein (1879 - 1955)
Physicist, Mystic and Nobel Prize winner

"I owe it to treating PSD holistically"

Karen Simpson,
Horse & Hound, 27 Oct 2011

"When we bought him we were told he cannot show jump. Since you treated him for PSD he has been successfully jumping!!"

"When we brought him home after staying with you for treatment for PSD he went out in the field and did the best extended trot I've ever seen him do!"

September 2010

"Thank you for sorting Whoop! He did his first competition since his PSD problems. 2nd, 1st, 2nd against the para team horses. He was fabulous! Thanks so much!"

Read the pdf testimonial from one satisfied client following treatment.

I simply cannot recommend

Roger and his team highly enough. My horse had become spooky, shooting forward and sideways to the point of being dangerous to ride. He couldn't canter united, did not want to go forward into a contact and was generally very unhappy. Vets diagnosed SI and Suspensory ligament damage which after several thousand pounds worth of treatment was only likely to improve his performance (and comfort) by 75%

After two weeks treatment with Roger, including Scenar, I not only have my old horse back but the new improved version! Not only did he stop spooking and rushing off immediately after his treatment, he is working better than ever. We are now nearly three months post treatment and Charlie continues to go from strength to strength. I couldn't be happier, thank you guys!

Jane Laid, Oct 2014

Proximal Suspensory Desmitis

Proximal Suspensory Desmitis (PSD) has been increasingly diagnosed in recent years as a cause of hind limb lameness. It is usually diagnosed based on gait analysis, perineural analgesia (local nerve block) of the deep branch of the lateral plantar nerve, and ultrasound of the proximal suspensory ligaments. PSD can be in one leg or both (bilateral). The proximal suspensory ligament is the top section of the suspensory ligament below the hock that is closer to the body than the low (distal) end!

The conventional recommended treatment options offer conservative treatment with a "large proportion of horses" having persistent or recurrent lameness, shock wave therapy with approximately 40% of horses returning to full athletic function or surgical treatment by neurectomy (cut the nerve) of the deep branch of the lateral plantar nerve and plantar fasciotomy (cut the soft tissue around the ligament to free it up) with approximately 70% of horses supposedly being able to return to full athletic function ... but for how long before the hock is crocked? The current advice should be that following surgery your horse would have between 2 and 5 years before they are no longer fit for work. Unfortunately, this information is frequently not given to owners to consider when making their decision about surgery. I believe this failure rate is yet another vindication of the theory that PSD is secondary.

The intensity of the work at the highest levels of competition is frequently blamed for the occurrence of this condition. On the face of the above information many supposed top horses have had and are recommended to go down the surgical route. This surgery used to render these horse ineligible to compete at FEI level, BSJA and BE although Vets have persuaded the FEI to change their rules to the detriment of horse welfare because they are more concerned about being subjected to disciplinary action than what's best for the horses. I wrote to the FEI to point out their rules were being flaunted on a par with administering a banned substance in my opinion, and this may have been a catalyst for the rule change. Unfortunately because the surgery is performed through a very small incision it is very difficult to tell if a horse has undergone this surgical intervention or indeed another similar de-nerving procedure elsewhere. Due to the value of horses competing at this level and the difficulty in spotting if such a procedure has taken place I believe there are a significant number of owners and riders who were encouraged to continue competing horses at FEI level in breach of the regulations. Having gone down this road of deception it becomes impossible to openly declare it within a Vetting procedure due to the implications for the previous owner and rider and the value of the horse unless the new owner/rider is prepared to continue the deception. There are obviously implications for the veterinary surgeons involved who may or may not be aware of the horse's history in a sale situation. There are potential safety issues for riders of neurectomised horses too that are being dismissed.

I find it interesting that the non-intervention option that obviously doesn't generate much income compared to treatment is only very vaguely stated as "not very successful". No actual success figure is quoted to enable owners to make a fully informed decision as to how much better shock wave therapy or surgery may or may not be, or am I getting overly cynical?! No other options are suggested either, yet there must now be a significant number of vets who know that I and others are having success with a more conservative approach.

I (and others) believe that in the vast majority of cases, PSD is not a primary condition in itself but is symptomatic of one or more other problems that alter the gait/posture and result in inflammation of the proximal suspensory ligaments. From the ultrasound pictures there can be no doubt that there is indeed inflammation present. However the fact that approximately 30% of horses having had the neurectomy (so that they can no longer feel the inflamed suspensory ligaments) still remain lame suggests that not only is the seat of lameness elsewhere, but that the perineural nerve block resulted in a false positive return to soundness during the lameness case work-up. On the wider stage this must question the efficacy of high leg nerve blocks. Do horses that still feel pain but cannot feel a significant portion their lower leg from a nerve block appear to become sound due to movement based on central locomotor memory rather than what they feel? ie do they move in a sound manner because of how their brain and muscle memory remembers it should do because they lack sufficient sensory function to co-ordinate adequately whilst continuing to respond to the remaining pain? This area needs research I think.

Coming back to the PSD itself I have been approached by a number of clients who decided to find another approach to the problem rather than go down the shockwave or surgical routes. Invariably a primary cause of the secondary PSD has been found and successfully treated using conservative techniques. This successful treatment by myself and others over quite a few years now, either together as a team or separately by focusing treatment outside the immediate suspensory ligament area, would seem to vindicate our position that PSD is a secondary condition indicative of other problems.

But what of those horses who have gone sound and returned to full athletic performance having undergone surgery? Well of course not all problems that alter gait are painful once the body compensates for that problem. In fact the figures suggest that 70% of causes that feed into bilateral suspensory desmitis are not necessarily painful in themselves once the gait has altered. However, the neurectomy and fasciotomy do not remove the underlying cause which will frequently manifest elsewhere over time and will inevitably lead to an exacerbation of the strain on the proximal suspensory ligaments that the horse can no longer feel. I have heard that there is a very poor prognosis for a subsequent lameness in a horse that has had a neurectomy in the past. The feedback I am hearing is that following neurectomy a significant number of horses subsequently go lame due to hock issues. This would seem to indicate that the PSD is there to warn of impending hock joint disease. Where is the sense in removing the warning mechanism? It would also indicate that the primary problems I and others focus on when treating PSD will continue to cause postural and gait issues unless identified and treated and will frequently lead to hock issues. This again confirms my position that PSD is a secondary symptom of a primary issue elsewhere.

It is not the role of a veterinary surgeon to perform a surgical procedure that falsely allows an individual horse to perform at a level that it cannot naturally sustain. Neurectomies should only ever be performed as a salvage procedure to enable quality of life in a retirement situation when all other avenues have been exhausted.

If a significant number of top performance horses are having this problem it either means that

  1. the individual horse is incapable of working at that level, or
  2. the training/management of that horse is inappropriate or
  3. we are asking too much of horses generally to expect them to perform at that level in which case vets should be highlighting this issue so that the FEI can alter tests and standards accordingly to find a different way of separating the stars from the also rans.

There is a strong argument for requiring all surgical procedures to be recorded in the Horse Passport by the performing vet. To date this has been resisted. Why?

The FEI could help limit occurrences of such injuries in other ways too. They should legislate to limit certain levels of competition to horses that have achieved a minimum age. Breeders put horses under pressure to grow quickly (bad for joints leading to problems such as OCD) so they can perform to a higher level and maximise price at an early age before they have fully matured and gained sufficient strength to perform the more advanced moves properly. Having an age limit on performance levels removes the need for this pressure and will ensure the top horses last longer too. My advice would be to steer clear of flashy young horses that are doing too much too young. They aren't strong enough in reality and will only lead to vet bills and tears.

If you have a horse that has been diagnosed with this condition I would recommend a more conservative approach to ascertain the reason behind why the suspensory ligaments are inflamed. By treating/correcting any other issue(s) that are treatable you will have a horse that is sound and far less likely to go lame in the future. If the reason for the proximal suspensory desmitis is conformational and/or untreatable it is better to find this out before you breed from them or push the horse harder in work which will inevitably create further health issues that could at worst have repercussions for the rider.

Clear scans mean all clear!

Since writing the above piece I have been approached on more than one occasion by owners who have had hind limbs scanned with a clear result for the suspensory ligaments. The vets involved however have decided to ignore the clear scan and have carried on treating for PSD regardless. This is outrageous - why perform a scan if the result is to be ignored, and why offer expensive treatment to an area that has been shown to be clear on investigation??

At the other end of the scale, I have recently heard about an owner who has been told that scans don't show PSD so it's a waste of time to do them and the horse should just be sent for de-nerving. So what are the scans that show inflammation doing?! I don't deny that the hind suspensories can and do get inflamed - they do! Where I diverge is in wanting to know why they've occurred and therefore how they should be treated along with the primary cause.

Do not be fooled by this approach. Scans are useful for a reason but should be believed for what they show and not for what the vet would like to see. Do not allow your horse to undergo unnecessary treatment without justification and certainly if the evidence is pointing to PSD not being the problem! If your horse is insured you are wasting your treatment allowance and risking unnecessary exclusions that might prove important in the future.

Don't mutilate immature horses

Just when I thought I'd heard all there is to hear that's bad about the denerving operation for PSD, I get an email from someone who has been recommended to have this surgery done on their 4 year old. Such a young horse is not fully developed and should NEVER be considered for such a dramatic and irreversible procedure. There are likely to be many more factors in a young horse that can feed into the proximal suspensory ligament area. These could range from developmental growth spurts, teeth issues, saddlery and farriery issues and inappropriate training techniques etc all of which will be variable, changing and easily sorted on an ongoing basis until the horse has fully matured physically and mentally. Do not be bullied into such drastic surgery for a procedure that should only ever, if at all, be a last resort salvage operation for an old horse.

Many primary issues are relatively minor and easily sorted

I've seen a number of horses and ponies over the years diagnosed with PSD as you might imagine! All were being encouraged to have surgery. One vet lost a client for refusing to refer a horse to me or for anything other than surgery. Luckily for the horse (already competing at FEI level!) the owner refused, sacked the vet and got me to have a look. There was little wrong with the horse other than a slightly rotated pelvis and questionable saddle causing a sore back.

Question: How many are having irreversible de-nerving surgery as a result of minor problems that are easily sorted?

Answer: All of them. Don't let your horse become part of that sad statistic.

The number of enquiries from distraught owners regarding horses recommended for surgery and euthanasia doesn't appear to be slowing down. Every horse I've seen has revealed reasons why the PSD has occurred that can be relatively easily sorted. PSD neurectomy surgery is now the most common claim for back leg lameness. I don't remember so many lame horses that never came right before which means we aren't making progress in the right direction.

It has been brought to my attention that some other vets are undermining my views and work on the basis that I'm somehow not an equine vet or that I'm a cowboy!! Well I am a fully qualified vet and most of my work is with horses. If that doesn't make me an equine vet then I'm happy not be labelled as one! I'm not into categorising people including myself anyway!

Frankly, under any circumstances I'm sure you'd rather get the correct treatment for your horse by a non-equine vet who thinks outside the proverbial box than be given the wrong treatment by an equine vet who's stuck in the proverbial!

As for me being a cowboy, I'm not the one who's advising owners to have their horse shot if they don't opt for ineffectual surgery. I'd accept that label if I am and if someone else is fixing all my reject cases for a fraction of the cost I charge, but I'm the one advocating pacifism and fixing what's been put in front of me. All my work comes through recommendation by word of mouth. If I don't get results nobody would recommend me. See testimonials on the left!!