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Proximal Suspensory Desmitis

Overview

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 basis of this information, it is not unreasonable to wonder how many supposed top horses have had, and are being recommended to go down the surgical route. This surgery used to render these horses ineligible to compete at FEI level, BSJA and BE. 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, the FEI have allowed vets to persuaded them to change their rules to the detriment of horse welfare because the advising vets were more concerned about being subjected to disciplinary action than what's best for the horses. De-nerving surgery is usually performed through a very small incision which makes it very difficult to tell if a horse has undergone this surgical intervention, or 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 previously 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. In my opinion there are potential safety issues for riders of neurectomised horses too that are being dismissed.

In Roger's experience of seeing many horses diagnosed with PSD is that in the vast majority of cases, PSD is not the primary condition in itself but is symptomatic of one or more other problems that alter the gait/posture and put excess strain on the suspensory ligament. This results in the inflammation that is found. From the work-up and ultrasound pictures there can be no doubt that there is indeed inflammation present.

The fact that approximately 30% of horses having had the neurectomy (so that they can no longer feel the inflamed suspensory ligament) 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. Why? This brings the reliability of high leg nerve blocks into question generally. Do horses that still feel pain but cannot feel a significant portion of their lower leg from a nerve block appear to become sound due to movement based on central locomotor memory rather than what they feel? In other words, 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? Roger isn't claiming to know the definitive answer to these questions. This is clearly an area that needs further research.

Coming back to the PSD itself, Roger has been approached by a significant number of clients over the years 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 Roger's approach. Roger isn't the only vet or professional who has come to the same conclusion. 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. If we weren't right the horses wouldn't come sound and stay sound too. The younger horses Roger that has treated have remained sound many years later and competed to a high level too.

But what of those horses who have gone sound and returned to full athletic performance having undergone surgery? 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 then 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. Roger has heard that there is a very poor prognosis for a subsequent lameness in a horse that has had a neurectomy in the past. Following PSD neurectomy, a significant number of horses subsequently go lame due to hock issues. Roger considers that PSD is the early warning light of impending hock joint disease. Where is the sense in removing the warning mechanism to something that is often a terminal lameness issue? Horses treated by finding the primary driving cause of PSD and resolving them all together do not go on to invariable get hock issues. Roger interprets this as further confirmation that PSD is a secondary warning symptom flagging a primary issue elsewhere.

Roger has sometimes been approached 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 wanted to carry on with surgery for PSD regardless. Why perform a scan if the result is going to be ignored, and why offer surgical interference including a neurectomy to an area that has been shown to be clear on investigation?

At the other end of the scale, Roger has heard about an owner who was 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 do show inflammation indicating then?!

Roger doesn't deny that the hind suspensories can and do get inflamed - they do! Where he diverges is in wanting to know why they're strained and inflamed, and therefore what else needs to be addressed as the primary cause alongside treating the suspensory injury too.

Scans are useful and have their place 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.

Just when Roger thought he'd heard all there is to hear that's bad about the denervation operation for PSD, he heard from an owner who had been recommended to have PSD surgery performed on their 4 year old. Such a young horse is not fully developed either skeletally or muscularly, and should NEVER be considered for such a dramatic and irreversible procedure. There are likely to be many more primary factors in a young horse that can temporarily feed into the proximal suspensory ligament area. These could include one or more of the following: developmental growth spurts, teeth issues, saddlery and farriery issues and inappropriate training techniques etc all of which will be variable, changing and easily managed on an ongoing basis until your horse has fully matured physically and mentally, by which time the issue may well no longer be present.

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.

Recommendations for "PSD surgery or euthanasia" continues. Every horse bar one that Roger has seen and examined has revealed a primary issue that has driven the secondary PSD that can be relatively easily sorted, even if it takes a bit longer in some cases. PSD remains one of the most common diagnoses for hind leg lameness in horses. Roger doesn't remember so many hind limb lame horses that never came right before PSD became so frequently diagnosed, which means progress isn't being made in the right direction.

It has also been brought to Roger's attention that there are some other vets who feel it necessary to undermining Roger's views and work rather than stand on their own results. One even told a potential client that Roger had been struck off! Apparently, Roger's opinion is less qualified on the basis that "he's not an equine vet", or "he's a cowboy"!! To be 100% clear, Roger is a fully qualified vet and most of his animal work is with horses. If that doesn't make him an equine vet, then Roger is happy not be labelled as one! Roger ploughs his own furrow in line with what he has learned, and the experience he has gained over the years, and follows the best ethics possible to do the best for the animals under his care as his foremost consideration.

However anybody is labelled, it's better to get the correct assessment and treatment for your horse by a "non-equine vet" or anybody else for that matter, than to be given the wrong assessment and inappropriate treatment by an "equine vet".

As for Roger being called a cowboy, He's not the one who's advising owners to have their horse shot if they don't opt for ineffectual surgery. He'd accept that label if he was, and if someone else was fixing all his reject cases for a fraction of the cost he charges. The fact is that Roger frequently manages to get horses right without surgical interventions, and usually for a fraction of the end cost of the surgery and aftermath.

All Roger's work comes through recommendation by word of mouth. If he didn't get results nobody would recommend him, as evidenced by the testimonials below.


PSD Testimonials

  • "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, 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
  • My old boy was diagnosed with a chronic injury to the suspensory ligament in both hind legs, low down where it branches at the fetlock when he was 14. We had 3 years of struggle with it, Liphook told me to put him down, and then someone recommended Roger Meacock at Natural Healing Solutions. Get in touch with him, if he can't fix the problem, then it probably isn't fixable!! Jeeves is 27 now and still in light work and he went back to dressage and showing after other vets told me he would never be paddock sound.
    – Madeline Taig
  • "A massive thank you to Roger for all the work with my horse Jeeves a few years ago now, this weekend he qualified for the Supreme Championship at the Veteran Horse Society Championship show in a couple of weeks, something we never thought he would do when he first injured his suspensories."
    – Madeline Heath
    Posted on FaceBook
  • "When we bought him we were told he cannot show jump. Since you treated him for PSD he has been successfully jumping!!"
    – A.N. Other
  • "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!"
    – Bert Sheffield,
    International Para-Dressage Rider for Canada
  • "I owe it to treating PSD holistically."
    – Karen Simpson
    Reported in Horse & Hound in 2011.

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