Ligament Injury - Surgery - The Horse Forum
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post #1 of 16 Old 03-04-2020, 06:09 PM Thread Starter
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Ligament Injury - Surgery

Hi everyone,

My mare seems to have some soft tissue injury to one hock. She has been x rayed and has also had an ultrasound. The vets found bony changes that suggest injury to her ligaments, and the ultrasound backed that up. They also found fluid in the joint. Other than stall rest, she said we can do surgery, but it would be more exploratory than say removing a bone chip. She said that by doing the surgery we can see more of what is going on and possibly clean up the joint and ligaments.

I probably have some of my info wrong because it was a lot of information to take in. I'm waiting for an email from the vet summarizing her findings and more info on the surgery should we opt for it.

Does anyone here have experiences with this type of injury, rehab, maybe even surgery? Words of caution, success stories even?
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post #2 of 16 Old 03-04-2020, 07:50 PM Thread Starter
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I recieved the clinical summary from the vet. I've condensed it a bit, there is a very long and complicated diagnostic explanation, if anyone is interested i can provide.

"Based on the history, clinical signs, and radiographic as well as ultrasonic imaging performed, Rocket has injured the collateral ligaments around her hock. During the ultrasound we also found a marked amount of material within the joint - this may be blood clots from old hemorrhage, fibrin from inflammation or enlarged synovium within the joint."

The surgery would clear out the material within the joint as well as any frayed tissues or torn ligament fibers within the joint capsule.

If we decide to go for the surgery, they recommend IRAP therapy afterwards. It's a regenerative therapy, harvested from Rocket's blood, processed and then injected into the hock.

Whether we do surgery or not, we have to have continued rest and confinement with gradual re-introduction to controlled exercise.

I'm not really sure what I'm looking for, I have to admit I'm very sad and troubled. It's a tough decision in regards to the surgery. The vet was very guarded about her ability to return to work as it was. Rocket is my long distance mount. We do competitive trail and extended packing trips into the back country.

Thanks for reading.
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post #3 of 16 Old 03-04-2020, 08:02 PM
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So my first questions when surgery is on the table is always as follows:

1. How much is this horse worth?
Sub questions: is surgery going to be worth it in the end to produce a (hopefully) completely sound horse that could be sold/win back the lost money in competitions?
Sub-sub question: is the cost of the surgery more than what another lease would cost you for the year or two Rocket is off?

2. How old is the horse? Any other medical history?
Sub questions: will going under present a risk for MORE harm or even death than letting the injury heal naturally?

3. What are my other options?

4. Is your diagnosing vet the one who would do the surgery, and if so, have you garnered a second opinion?
(Sub point - will this person get more money off of you if you say yes, and if so have you asked someone with no paycheck in the game?)

5. Is the horse insured and will insurance pay for this surgery?
(if yes, rate of consideration goes way up for me, since I am not footing the bill).

6. Has this injury been a persistent problem or is it an acute, new diagnosis?

All of this said and done - what is the surgery worth for you? You already said you're not sure what you want to get out of asking about it so go back to that.
Why are you hesitant? Does it pertain to something above, or another point entirely?

Any surgery going into a joint is highly risky - even commonly done joint injections can go detrimental quick. Joints are a one and done kind of deal - if you mess them up they're messed up forever and the rate of return to level of work is quite low for any type of sport horse.
As I asked, is this vet someone you trust to do this? To have you and Rocket's absolute best interests at heart? Would this surgery do way more for Rocket than traditional rest and rehabilitation would?

It's a lot of questions to ask, but you know your horse and yourself best, as well as your pocketbook.
IRAP is expensive but in my experiences with it does AMAZING things for healing injuries, so there is that.
Good luck and healing vibes to Rocket :)
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post #4 of 16 Old 03-05-2020, 10:39 AM Thread Starter
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Thank you for your well thought out reply!

1. How much is this horse worth?

If I were to sell her, I'd price her at $5500. The mare is broke, solid and safe. Although her career has been short with just one season, she placed well. She has a beautiful flat walk, run walk and canter. Good pedigree.

Sub questions: is surgery going to be worth it in the end to produce a (hopefully) completely sound horse that could be sold/win back the lost money in competitions?

More than likely no, she will not be able to return to competition, at least not the type that we do!

Sub-sub question: is the cost of the surgery more than what another lease would cost you for the year or two Rocket is off?

I have another mare that I can use for this season, so I won't have to purchase or lease another mount while Rocket is off.

2. How old is the horse? Any other medical history?

She is five. No prior history of lameness or illness.

Sub questions: will going under present a risk for MORE harm or even death than letting the injury heal naturally?

There is a risk that when she gets up from surgery, she will tear her already injured ligaments. I wonder though, don't we face this every time she lays down in her stall?

3. What are my other options?

The vet said no steroids in the joint, it's too angry and inflamed. Maybe we can do IRAP without surgery? I didn't ask about that.

4. Is your diagnosing vet the one who would do the surgery, and if so, have you garnered a second opinion?

Our diagnosing vet brought in a specialist to do the ultrasound. It was this specialist that provided the surgical option.

(Sub point - will this person get more money off of you if you say yes, and if so have you asked someone with no paycheck in the game?)

Yes they would and no I haven't. Fair point.

5. Is the horse insured and will insurance pay for this surgery?
(if yes, rate of consideration goes way up for me, since I am not footing the bill).

No she is not insured.

6. Has this injury been a persistent problem or is it an acute, new diagnosis?

It has been a persistent problem since end of November. She came in from pasture with a blown up hock. It was quite icy so we thought she slipped and banged her hock. Isolated her right away. The swelling went down, but she flared back up. So we isolated her again for two months, and then she had another flare up. That brings us to now.

All of this said and done - what is the surgery worth for you? You already said you're not sure what you want to get out of asking about it so go back to that.
Why are you hesitant? Does it pertain to something above, or another point entirely?

The money is not an issue, the surgery is $2500, and while an inconvenience, if they could say it would drastically help her I would do it in a heart beat. I don't want to go through with surgery if we can get the same results with stall rest.

Any surgery going into a joint is highly risky - even commonly done joint injections can go detrimental quick. Joints are a one and done kind of deal - if you mess them up they're messed up forever and the rate of return to level of work is quite low for any type of sport horse.
As I asked, is this vet someone you trust to do this? To have you and Rocket's absolute best interests at heart? Would this surgery do way more for Rocket than traditional rest and rehabilitation would?

I do trust the specialist, we have a really good relationship with our vet too. They have always been honest and treated us well in the past. The only thing the surgery can do that rest cannot, is remove any material from the joint. But there's a good chance she can't remove anything or it fills back up.

It's a lot of questions to ask, but you know your horse and yourself best, as well as your pocketbook.
IRAP is expensive but in my experiences with it does AMAZING things for healing injuries, so there is that.
Good luck and healing vibes to Rocket :)


Thank you again, you really made me focus my thoughts!
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post #5 of 16 Old 03-09-2020, 10:03 AM
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Of course! If you haven't noticed, I've been down this block many times with both horses and other animals. Writing it all out and focusing on important points is always beneficial.
Keep us updated!
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post #6 of 16 Old 03-13-2020, 12:27 PM Thread Starter
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Do you have experience rehabbing a ligament injury? My mare has been on stall rest for almost two weeks now, next week we start hand walking as per the vets instructions. Any tips or tricks?

Realistically, can she ever go back out to pasture? I have been stalking threads on other forums and some people never turn their horses out again after this kind of injury, they put them in a smaller paddock so they can't get up to shenanigans.

My husband and I have decided NOT to go ahead with surgery. It wasn't about the cost so much as the potential outcomes from surgery were not exponentially greater then rehabbing her without.

Getting her used to stall rest was quite an adjustment, but she seems to be in good spirits now.
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post #7 of 16 Old 03-13-2020, 01:11 PM
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Here's some info I found on the IRAP, nothing about price but I left the clinic's contact info in case you wanted to contact them to find out more. I am not familiar with IRAP, have not ever done it nor known anyone who has, so no input there. Based on what you have said and the prognosis given, I would just do stall rest/hand walking for as long as it takes to give her time to heal, probably close on 6 months. Would she ever go back out to pasture? Well, here she would, at least once. If she went out and immediately flared back up again, then that would be the end and we'd look at pain level, quality of life and so on before we made any more decisions.

IRAP Harvesting & Injecting
Interleukin-1 Receptor Antagonist Protein (IRAP) is a new and effective intra-articular treatment for joint disease marketed by Arthrex VetSystems in the USA. The product was originally developed in Europe, and has been used extensively in Germany. IRAP is an anti-inflammatory protein that counteracts the destructive effects of inflammatory proteins such as Interleukin-1 (IL-1) that are produced within inflamed or arthritic joints. The IRAP system has been designed to stimulate the horses’ own white blood cells to produce anti-inflammatory mediators and enzymes, specifically Interleukin 1 receptor antagonist protein (IRAP), which can reduce the inflammation present as a result of degenerative joint disease. Treatment with IRAP utilizes progressive gene therapy to combat osteoarthritis in your horse.

The process of harvesting IRAP is quite simple and can be performed as an outpatient and/or potentially on the farm. Blood is collected from the jugular vein and incubated for 24 hours in special syringes that contain glass beads that induce the white blood cells present in the blood to produce and secrete therapeutic proteins, namely, IRAP.



After 24 hours the blood is centrifuged and the serum is separated from the red blood cells. The protein rich serum is then split into 3-6ml doses and the separate doses are frozen for use at a later date.



Typically each collection produces enough serum for between 3-5 injections. It is important to note that the injections are only suitable to treat the horse from which the original blood was collected. The injections can be stored for up to 12 months from the date of collection.

Degenerative joint disease is one of the biggest causes of poor performance and a decreased competitive lifespan in the horse. This is true for all types of equine athletes, from racehorses to dressage and show jumping horses. Both young and old horses can be affected by degenerative joint disease resulting in a loss of athletic ability and possible early retirement.

When injected into a joint, the IRAP protein rich serum stimulates a regenerative response from cartilage cells, through a process of cell division and increased cell recruitment. This is actually what sets IRAP apart from other intra-articular treatments for joint disease. The fact that IRAP stimulates cartilage cells means that it has a disease modifying component as well as an anti-inflammatory component. The serum also contains cytokines that act to reduce inflammation within the joint. In addition there are other anti-inflammatory proteins produced during the incubation process that work synergistically with the cytokines to further reduce the inflammation within the diseased joint.

What does the treatment with IRAP involve?

The therapy involves three joint injections at 7-14 day intervals. Most positive effects are seen after the second and the third treatment. The majority of horses will be sound after the third injection. In our hands, more than 90% of horses have returned to soundness after IRAP therapy. After injection, we routinely bandage the joint if possible for 2 days, and the horse should be kept on 3 days of strict stall rest, followed by a period of of hand-walking (30-45 minutes). Once the course of injections and the final hand-walking period is completed, horses should receive one week of ridden walk exercise, followed by one week of ridden walk and trot, before returning gradually to regular training programs*.

*It is important to note that the instructions may vary, depending on the primary joint disease.

Obviously, as with any joint injection, the joint should be monitored carefully for any signs of infection (heat, swelling, and increase in lameness) – if you notice any of these signs, please contact us.

Once the horse is sound, the horse can resume normal work. If lameness returns after a period of time, any remaining frozen samples can be defrosted and the injections repeated. Often a single injection will suffice at this point and it is unusual for most horses to need to repeat the full course of three injections. However, individual cases can vary and each case will need to be reassessed by your veterinarian if lameness returns.

What cases warrant the use of IRAP?

The cases that generally respond the best to IRAP therapy are those with mild to moderate radiographic signs of degenerative joint disease where the lameness has been localized to a particular joint or joints.

Indications for use of IRAP in the joint include horses with a well defined synovitis/capsulitis, particularly those horses that do not respond well to conventional anti-inflammatory joint medication and horses that have had arthroscopic surgery and have been found to have focal cartilage diseases.

IRAP is NOT recommended for use in tendon sheaths or bursae, in joints where there are bone fragments, fractures, meniscal or ligamentous injury unless it has been successfully treated arthroscopically, in bone cysts, or in horses with advanced osteoarthritis (low success rate).

IRAP is very useful after arthroscopic removal of any chip fragments. In these cases the anti-inflammatory cytokines and proteins reduce inflammation within the joint and encourage a regeneration response from the damaged cartilage. In post surgical cases, we recommend administering the first IRAP treatment between 4 and 10 days after surgery. We recommend that post surgical cases receive the full course of three injections at one week intervals.

Why use IRAP?

IRAP is different from other products because it treats the cause of joint disease and its action is aimed at restoring joint lining and cartilage function. Studies performed in Colorado State University show that treated horses demonstrate reduced lameness, improved joint histology (cellular make up) and a tendency towards cartilage preservation. Our clinic has seen resolution of lameness, a general improvement in the range of motion of the joint and a decrease in joint effusion in treated horses.

Traditionally the most common intra-articular medication for the management of joint disease has been cortisone injections. Clinically, with cortisone injections we often see a sudden response and improvement in the degree of lameness that then gradually wears off over a period of time (6-12 months). When cortisone injections are repeated we often see a decrease in the interval between treatments. Meaning, that the more cortisone injections a horse has into a particular joint, the shorter the duration of therapeutic effect and the sooner that joint will need to be treated again. The use of IRAP often allows us to delay the use of cortisone injections and prolong the athletic life of the horse. In many cases where there has been a very good response to IRAP therapy, cortisone injections to manage the degenerative joint disease can be delayed indefinitely.

Another advantage to using IRAP therapy, is that it does not have some of the same side effects as cortisone. The use of IRAP therapy does not increase the risk of laminitis and there is a smaller risk of joint infection using IRAP compared with using cortisone. Adverse effects of this product have not been reported after extensive use in people and horses in Europe. There have been a few reported cases of reaction to IRAP serum with a ‘flare’ response seen within 24hrs of injection. This is an uncommon side effect that subsides after administration of systemic corticosteroids and application of ice to the joint.

IRAP is another therapy to be added to the battery of tools that we have to combat osteoarthritis in your horse. The reason IRAP is so exciting is its’ potential for a long-term effect on battling osteoarthritis. Whereas some of the therapies listed above might only have short-term effect, IRAP has the potential to stop the cartilage matrix from being degraded and increase healing. IRAP has the ability to stop the inflammation cycle and bring comfort to your horse. The research on IRAP is ongoing but the results have been very encouraging.

Typical cost:

Please contact our office for pricing information:

781-585-2611, [email protected], or click here

IRAP harvesting and preparation is usually performed as an outpatient service of South Shore Equine Clinic, as processing of the blood should occur as soon as possible from the time of blood draw. In special circumstances it has been performed stall side.

Please contact us if you are interested in learning more about IRAP or if you think your horse is a candidate for IRAP therapy!

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post #8 of 16 Old 03-13-2020, 02:00 PM
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Quote:
Originally Posted by MajorSealstheDeal View Post
Do you have experience rehabbing a ligament injury? My mare has been on stall rest for almost two weeks now, next week we start hand walking as per the vets instructions. Any tips or tricks?

Realistically, can she ever go back out to pasture? I have been stalking threads on other forums and some people never turn their horses out again after this kind of injury, they put them in a smaller paddock so they can't get up to shenanigans.

My husband and I have decided NOT to go ahead with surgery. It wasn't about the cost so much as the potential outcomes from surgery were not exponentially greater then rehabbing her without.

Getting her used to stall rest was quite an adjustment, but she seems to be in good spirits now.
I had an Appaloosa/TB cross mare do something similar. Stepping into a post hole did the damage. Had to give her 6 months stall rest, then begin hand walking. She was my first Dressage horse. Never recovered enough to return to competition, but she was able to be ridden walk/trot if not pushed too much. Trails were not doable, and so she was a brood mare for me then a pasture pet after giving me two spotted fillies.
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post #9 of 16 Old 03-13-2020, 03:02 PM Thread Starter
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@Dreamcatcher Arabians Thank you for the info on IRAP. It would cost $1000 CAD to get it done here. The recommendation was to to IRAP in conjunction with the arthroscopy, which the info posted seems to agree with. The vets were very much against injecting any steroids into the joint since it is was already so irritated. I also don't know anyone who has done it.

@AnitaAnne , thanks for sharing your experience. I also suspect something like a post hole got her. We have been talking about using her as a broodmare in the future, if we can get her pasture sound.
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post #10 of 16 Old 03-14-2020, 11:32 AM
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Quote:
Originally Posted by MajorSealstheDeal View Post
Do you have experience rehabbing a ligament injury? My mare has been on stall rest for almost two weeks now, next week we start hand walking as per the vets instructions. Any tips or tricks?

Realistically, can she ever go back out to pasture? .
Put simply... drugs. Rehabbing is dangerous for both handler and horse as they've been cooped up and can be unpredictable. I've been thrown, kicked, spun off etc from rehabbing horses that are otherwise absolute angels.
Talk to your vet about dosages and what will work best for you. Resurpine may be a good option for the long term, but a lot of people use a day by day basis and ace as needed for the start of tack walking.

As for pasture, that is up to your vet. LISTEN to your vet and what they have to say. They know the injury and the horse best. I do not turn out normally, but have a mare I'm giving a full year off to be bred who's injured who can do whatever she likes in her run. It's a horse by horse basis, but I would say listen to vet instructions.

IRAP is an amazing thing, I've seen it do wonders to injuries!
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