Superficial digital Flexor Tendonitis (Bowed tendon) in a Horse!

A  twenty year-old mare presented for sudden, severe swelling of the left front lower limb. The mare was nearly non-weight bearing lame and had been seen galloping around her paddock moments before. Prior to my exam, the mare was stalled for 7 days and treated with ice and systemic non-steroidal mediation (phenylbutazone). On presentation there was a noticeable "profile" to the lower portion of the forelimb (Red line:Figure 1). The mare was moderately positive to pressure over this swelling and was lame at the walk. On palpation, there was no distinction between the superficial digital flexor tendon and the deep digital flexor tendon.

Figure 1

Ultrasound examination of the lower limb, beginning just below the knee (carpus) revealed inflammation of the superficial digital flexor tendon (SDF). The inflammation was moderate just below the knee (Figure 2) however became severe further down the leg (Figure 5). In Figures 2 and 3, moderate to severe edema (dark tissue) is noted with pockets of disrupted fiber pattern. The image in Figure 4 is of the opposite limb for comparison to /the abnormal limb. In Figure 5, the SDF tendon (Red arrows) is severely enlarged and there is no apparent pattern with regards to the fiber pattern. These findings are consistent with a near rupture of the SDF tendon.

Figure 2

Figure 3

Figure 4

Figure 5

Although the outward and inward findings are severe, the prognosis for pasture soundness is good. It will take 6-12 months for this type of injury to heal with a fibrotic scar but the mare is likely to return to soundness as a pasture horse. Unfortunately, her prognosis as a riding horse is poor and it is not recommended to return this mare to any type of forced work due to her age and degree of injury. Tendonitis of the superficial flexor tendon can occur in various regions of the lower limb. The closer to the knee/carpus (High bow), the worst the prognosis, even for pasture soundness. This is due to the constant irritation of the tendon when the horse advances the limb. In addition, horses that suffer a "bowed" SDF tendon are at increased risk for another injury to the same tendon and it commonly occurs above or below the original injury. My recommendation for rehabilitative care includes the following:

1: Limited activity: preferred stall rest with hand walking for 2 months followed by small paddock turn-out
2: Daily ice therapy for 2-3 weeks
3: Topical non-steroidal cream: Surpass
4: Consider Extra-corporeal shockwave treatment and PRP injection.

Distal Check Ligament Injury in a Horse

A 14 year-old, warm-blood mare presented for a sudden swelling along the upper region (2 inches below the carpus on the back of the leg) of the flexor tendons in the left forelimb. The mare was mildly to moderately positive to palpation of the swelling yet no obvious lameness was observed when trotted in hand. Careful palpation of the area isolated the swelling to the distal check ligament/deep digital flexor tendon area of the proximal metacarpus. Approximately 2-3 inches below the knee/carpus of a horse, 4 soft tissue structures can be identified on ultrasound exam (Figure 1). The ligaments and tendons are typically assessed in a cross-sectional plane (Figure 1-3) and in a longitudinal plane (Figure 4). The most superficial is the superficial digital flexor tendon (SDF), followed by the deep digital flexor tendon (DDF), followed by the distal check ligament, and finally the deepest soft tissue structure which is the proximal suspensory ligament. The first two structures (DDF and SDF) are tendons and should appear identical with regards to brightness (echogenicity) on ultrasound. The deep structures (check ligament and suspensory) are ligaments and tend to be brighter on ultrasound exam when compared to the tendons. The overall echogenicity should be the same or homogeneous throughout the body of the tendons and ligaments.

Figure 1

In Figure 2, a clear, black lesion is identified along the outside/lateral aspect of the distal check ligament. The entire image appears slightly side-ways or oblique in order to optimize visualization of the ligament injury (Red circle in Figure 3). The "black hole" or core lesion corresponds to an area of ligament fiber disruption, edema, and possible blood accumulation.

Figure 2

Figure 3

In Figure 4, the same area is examined in a longitudinal plane to assess the extent of the fiber disruption. The area of disrupted ligament appears to include nearly the entire length of the distal check ligament. Although there is significant edema and contrast between the check ligament and the surrounding structures, the ligament appears to be intact. On a scale of mild, moderate, and severe, I would grade this as moderate with regards to degree of injury to the distal check ligament.

Figure 4

The image in Figure 5 is a simultaneous cross sectional and longitudinal image of the injured ligament.  Of all the soft tissue structures to injure in this region of the horse's limb, the distal check ligament is the least important with regards to long term prognosis and return to work. In my experience, many horses with this injury demonstrate little if any lameness at the time of injury but an obvious swelling is always present. Lameness in these horses is typically reserved for the severe injuries which involve a tear of the distal check ligament.

Figure 5

Care for horses with this type of injury include forced rest, ice, topical anti-inflammatory medication (Surpass cream), platelet rich plasma injection (PRP), and extra-corporeal shockwave treatment. At a minimum, the horse needs to be stalled with hand walking only for 6-8 weeks followed by 6-8 weeks of a controlled rehab program. During this time, daily ice treatment is ideal. However, I have had patients that did not agree to the stall rest and were merely turned out for several months. These horses healed with a prominent thickness to the ligament but were sound and return to full work. In my experience, the combination of PRP injection followed by a series of shockwave treatment results in a smaller scar (thickening of the ligament). I have been involved in 2 cases that resulted in surgery to remove the distal check ligament. In one case, the ligament had been injected with cortisone which resulted in  abscessation of the ligament and in the second case, the injury was not allowed to heal properly before returning the horse to work!  Although these types of injury have a good prognosis for full return to work, the horse does need time off and I strongly recommend regular evaluations for soundness and follow-up ultrasound exam.

Testicular Enlargement in a Stallion

A 19 year-old stallion presented for the complaint of testicular enlargement. On physical exam, the left testes palpated firm, non-painful and was approximately 30-40% larger than the right testes (Figure 1). The potential differentials for an enlarged testes in a stallion include testicular neoplasia (cancer), hydrocele, scrotal hernia, testicular torsion, and orchitis. Definite diagnosis is based on ultrasound exam and histologic exam of the abnormal tissue. Ultrasound exam of the stallion's testes was performed during the initial visit.

Figure 1

In Figures 2 and 3, the left testes is imaged via ultrasound. The testicle appears to be divided by two tissues-types which vary in density or echogenicity (degrees of brightness). The normal tissue appears brighter or hyper-echogenic whereas the abnormal tissue appears darker or less echogenic. The edges of the abnormal tissue are distinct and there are multiple, small "stars" or areas of increased echogenicity throughout the abnormal tissue. 

Figure 2

Figure 3

Ultrasound exam of the right testes revealed a homogeneous tissue consistent with normal testicular structure (Figure 4). The echogenicity did NOT vary throughout the testicle and the over-all size of the testicle was less than the left testicle. In Figure 5, the left and right testicles were imaged simultaneously and the difference in testicular architecture becomes more clear when comparing the "normal" right tests to the "abnormal" left testes. 

Figure 4

Figure 5

Testicular neoplasia or cancer is relatively rare in stallions compared to dogs. The types of cancer include seminomas, sertoli cell tumors, and leydig cell tumors. Histopathologic exam is required to determine the type of testicular cancer. All three types of cancer will result in compromise of normal sperm-producing tissue and thus reduction in fertility. Seminomas are the most common of the three types of testicular cancer in stallions and may have a high degree of malignancy and invasiveness. Scrotal hernia, testicular torsion and orchitis are additional causes of testicular enlargement which are typically associated with varying degrees of pain and inflammation. Ultrasound findings of these conditions may include small intestinal loops, dilated vascular supply and pockets of purulent debris. Similar to testicular cancer, these conditions typically alter the conditions for normal sperm production and will reduce fertility. A more benign cause of testicular enlargement is known as a hydrocele. This corresponds to an accumulation of abdominal fluid within the scrotal sac. Although benign, the increase in fluid may cause change in temperature and pressure which will also affect sperm production. This condition is more easily confirmed with ultrasound exam alone!.

The stallion in this case is scheduled for surgical removal of the affected testes for definitive identification of the cause for the testicular enlargement. Stay tuned!! 

Injectable Supplements for Horses

Listed below are the most common (non-steroidal) injectable supplements administered to horses to treat for active arthritis and hopefully slow down the development of arthritis. These medications vary in cost, method of administration, and approved use. One of the best known and most commonly used is Adequan. The active ingredient in Adequan is polysulfated glucosaminoglycan (PSGAG) and is FDA approved for intra-muscular and intra-articular use in horses. It is reported that PSGAG-containing products, such as Adequan, work by reducing inflammatory mediators within the joint and help maintain healthy cartilage. Adequan may be given in a loading dose initially for 5-7 treatments and then once monthly or may be administered every 6 months as a loading dose of 7 treatments that are 4-7 days apart.

Figure 1: Molecular structure of Adequan

Figure 2: Intra-articular Adequan

Similar to Adequan , a relatively new supplement in the US is known as Pentosan. The active ingredient in Pentosan is Pentosan Polysulfate Sodium (PPS) and is distinct in molecular structure from Adequan (Figure 1 versus Figure 3) . In humans, PPS is used to treat bladder pain associated with cystitis. In addition, clinical research in humans suggests that PPS may reduce clinical signs associated with arthritis. In horses, clinical and empirical data indicates that regular administration of PPS-containing products reduces clinical signs associated with osteoarthritis. Pentosan is available in the United States as a generic product that is sold through compounding labs (Figure 4). In my practice, it is commonly administered as an intramuscular injection, initially as a loading dose (5 injections, 1 week apart) and then 1-2x per month.

Figure 3: Molecular structure of PPS

Figure 4: Generic Pentosan

A PPS containing product that is licensed for use in horses in the US and FDA approved is PentAssuie (Figure 5) . This product  contains both Pentosan AND N-acetyl glucosamine (PSGAG). N-acetyl glucosamine is a PSGAG but is slightly different in structure compared to Adequan. PentAussie is approved for post surgical lavage and is considered "off label" when administered intra-muscularly. 

Figure 5

The product known as Legend is an injectable supplement approved for use in horses that contains Hyaluronate sodium which is non-sulfated glycosaminoglycan. Hyaluronate is a normal constituent of joint fluid and plays a key role in regulating inflammation within the joint. The product Legend is typically administered intravenously however products containing hyaluronic acid are injected directly into the joint. The frequency of IV administration varies from prior to competition to monthly.  

Figure 6

 Polyglycan (Figure 7) is an injectable supplement that contains a mixture of several productions (Figure 8). It is approved for use in horses but NOT for intravenous administration, which is the most common route of treatment! The product contains hyaluronate, acetyl glucosamine, and chondroitin sulfate (active ingredient in Cosequin).  In my practice, this supplement is administered several days before competition and/or on a monthly basis.

Figure 7

Figure 8

Obviously there is much more information to consider when choosing one of the above for your horse. These are the general guidelines I strongly recommend:

1: Once a horse is old enough to begin training, I recommend an "injectable" supplement to be administered monthly for the duration of that horse's career. Injectable supplements are likely to be superior to oral supplements.
2: Generally speaking intra-muscular injections are less expensive and can be done at the barn by the owner/barn manager. As such, I recommend starting with one of these supplements which include Adequan, Pentosan, and PentAussie.
3: Polyglycan is a great product and should be considered as an "in-addition-to" supplement to be used in horses that are in heavy competition or suffering from advanced osteo-arthritis.
4: The money you spend on a monthly basis for these "injectable" supplements is likely to be the best long term investment you can make for your horse besides having a good farrier and competent veterinarian!! 

Cystic Calculi in a Horse

A teenage gelding presented for the complaint of increased urination (polyuria) and increased water intake (polydypsia). The increased urination had become a significant issue since it was happening at all times including when under saddle and showing. The physical exam was normal and a blood sample was collected for CBC and chemistry analysis. In addition, a free-catch (non-sterile) urine sample was collected during the exam. The CBC and chemistry results were normal suggesting that a primary problem of the kidneys may not have been the cause for the frequent urination. However, the urine sample contained traces of blood, moderate calcium crystals, and moderate white blood cells. These findings suggested an inflammatory process either in the urinary bladder or urethra. A endoscopic exam (cystoscopy) of the urinary bladder was performed. In Figure 1, the internal cavity of the urinary bladder is visualized. A pool of urine is present and a large, yellow object consistent with a urinary bladder stone (cystic calculi) is located in the center of the bladder. The surface of the bladder stone is rough and spiculated. In Figure 2, the inflammation caused by the abrasive stone can be visualized. 

Figure 1

Figure 2

In Figure 3, a pool of "debris" is noted surrounding the bladder stone. This debris is likely made up of calcium crystals, purulent matter (white blood cells), and some bacteria. The irritation caused by the bladder stone likely resulted in hemorrhage within the urinary bladder which is a great media for bacterial colonization! As such, chronic urinary bladder infection or cystitis is a common problem in these patients that will not resolve until the stone and debris is removed. A bladder stone this size can only be removed through a surgical procedure. There are two options regarding surgical approach: 1: bladder exploration via an abdominal incision or 2: through a urethrotomy within the perineum. The latter is performed in a standing horse and is limited to small bladder stones.

Figure 3

The cause of urinary bladder stones in horses is believed to be in part due to diet. Horses consuming diets high in calcium such as alfalfa and drinking water that has a high calcium content may be predisposed to developing urinary bladder stones. However, the condition is relatively rare when one considers how many horses are fed a pure alfalfa diet!  In addition, horses can develop stones in the bladder AND kidneys. These stones may travel and lodge within the ureters and the urethra. In my clinical experience, I have diagnosed urinary bladder stones in 2 geldings and 1 mare. In addition, I have diagnosed kidney and ureter stones in 2 geldings and 2 mares. If the stones obstruct the flow of urine from the kidneys into the urinary bladder they will ultimately result in compromise of kidney function. Common clinical signs include increased urination, increased water intake, recurrent low-grade colic, fever, blood in urine, and poor performance.

Arytenoid Chondritis in a Horse

A 12 year old quarter horse mare presented for a 2-3 month history of coughing and "wheezing". The mare had developed the symptoms some what suddenly and was responsive to systemic corticosteroids. As such, it was initially thought that the mare was developing signs of heaves or COPD (chronic obstructive pulmonary disease). Heaves is relatively common in the southeastern United States and is a chronic progressive condition that involves an allergic condition that affects the lungs and causes fibrosis and scarring.     At presentation, the client was interested in finding out for sure what was causing the coughing and wheezing. Re-breathing exam was essentially normal with no wheezing detected or coughing. The mare was currently being treated with corticosteroids and had been for the past 48 hours. The initial plan was to scope the mare and perform a bronchoalveolar lavage (BAL) to confirm the diagnosis of heaves. However, when the endoscope was passed to the point of the larynx, we discovered what was the true problem!

Figure 1

In Figure 1 and 2, the larynx of the horse in question appears grossly abnormal. In Figure 1, the horse is in between breaths and there is thin slit between the arytenoids which consists of her airway. In Figure 2, the mare is taking a deep breath and the full extend of her airway is probably the diameter of a sharpie pen! There is large linear ulcer that crosses the left arytenoid cartilage and the significant thickening of both left and right arytenoid cartilages suggest chronic inflammation. In Figure 3, a "normal" endoscopy demonstrates what the full extent of the airway should be during inspiration and what normal arytenoid cartilage should look like!

Figure 2

Figure 3

Arytenoid chondritis is a relatively common cause of coughing and nasal discharge in older horses. This mare was a bit on the young side to have developed this condition. The causative agent is not clear but it is believed to be a combination of chronic irritation that is made worse by bacterial infection. In my experience, I have diagnosed this problem in horses that were exposed to a chemical irritant in agriculture setting such as dairy farms and produce farms; however, I have not been able to determine what chemical is causing the problem. Unfortunately  once the condition becomes chronic and the arytenoids are permanently disfigured, the only viable option is to perform a permanent tracheotomy. Surprisingly  horses do very well with permanent tracheotomies as long as they do not go swimming!! Clinical signs will improve with systemic corticosteroids and throat spray however these treatments will NOT reverse the damage done!!  This case, once again, demonstrate the importance of an endoscopic exam EARLY in the disease process.

White Line Disease and Laminitis in a Horse!

Figure 1

 The radiograph in Figure 1 is that of a middle-aged gelding that presented for intermittent foot pain. One year prior, the gelding had developed a high fever of unknown origin (presumed viral). During the weeks that followed the high fever, the gelding was slow to walk in small circle and on concrete surfaces. Over several months, the gelding's lameness improved however he was consistently tender immediately after being trimmed by the farrier.  There are 2 disease processes identifiable in Figure 1. The first is chronic laminitis or founder.

Figure 2

 In Figure 2, the yellow lines correspond to the dorsal hoof wall and the dorsal aspect of the coffin bone. Normally, these lines are parallel to each other such that a horizontal line drawn across them would yield equal angles (angle A and angle B). However, when the coffin bone has "rotated" from its axis then the angles will differ as they do in Figure 2. Hence, the radiographic finding is consistent with laminitis (founder) and subsequent coffin bone rotation. This condition appears to be chronic, evidenced by the "flaring" of the tip of the coffin bone seen in the blue circle in Figure 3. This flaring often corresponds to small fractures of the tip of the coffin bone secondary to increase concussive forces over the toe region of the foot. The red arrow highlights the extremely thin sole which measured less than 5 mm!  Ideally, the sole depth at the tip of the coffin bone should measure between 10-15 mm in thickness.

Figure 3

 The second disease process noted in these radiographs is White Line Disease. This is evidence by the gas lucency traveling up the dorsal hoof wall (yellow arrows in Figure 4). The lateral radiograph is only 2 dimensional hence it is impossible to predict if this gas lucency is right down the middle of the hoof or if it wraps around the medial and lateral aspect of the hoof. Regardless, the gas lucency corresponds to separation of the hoof wall from the underlying tissue. White line disease may be the primary problem or secondary. In this case, it is likely secondary to the chronic founder/laminits however in primary cases, it can cause coffin bone rotation and result in laminitis. This condition results from the accumulation of dead/decaying material that slowly works its way from the sole surface up the hoof wall. The offending organism is believed to be in part anaerobic bacteria that thrive in a low-oxygen environment and produce gas that can be seen on a radiograph. Excessive gas accumulation may result in hoof wall separation from the coffin bone and coffin bone rotation.  Treatment involves aggressive removal (hoof wall resection) of ALL dead and decaying hoof wall to expose the offending organisms. Hoof wall resection along is very effective in treating this condition but it is typically paired with soaking the foot after resection in a variety of solutions to kill off the offending organisms.

Figure 4

Often, the early signs of white line disease can be detected at the time of hoof trimming and appear as a shallow crack at the toe region. The opposite foot of this horse had the very beginnings of white line disease evidenced by a small amount of gas lucency noted at the very tip of the hoof (Figure 5). When identified at this early stage, the condition is easily managed with regular balanced 4-pt trimmings by the farrier. Successful  management of white line disease is best accomplished through a farrier-veterinarian team effort. The farrier is the most important part of the team since they will be doing 99% of the work. The veterinarian will provide the radiographic studies to verify that adequate exposure of the diseased foot is accomplished.

Figure 5

EPM in a Horse

A middle-aged Quarterhorse gelding presented for a history of strange gait and apparent pelvic limb weakness. The clinical signs developed suddenly over 24 hours. The gelding was current on vaccination for West Nile virus, Eastern Equine Encephalitis, and rabies. Neurologic exam noted a gelding in good body condition, alert, responsive yet quite "wobbly" in the hind limbs. Closer examination of all 4 limbs revealed severe weakness in both hind limbs. The degree of weakness was significant enough that the horse was having difficulty remaining standing. Importantly, the hind limb weakness was NOT symmetrical but was more severe in the left hind limb compared to the right hind limb. In the video below, the gelding is bearing most of his weight on the forelimbs and the result is a tendency to spin on the hind limbs due to the severe weakness of the pelvic limbs. 

Based on the neurologic exam, the most likely disease processes affecting this horse include Equine Protozoal Myeloencephalitis (EPM), spinal cord trauma, Eastern Equine Encephalitis (EEE), and West Nile Encephalitis. The sudden or acute onset of clinical signs is most consistent with spinal cord trauma however there was no history of a traumatic event and there were no external signs of such. Equine Protozoal Myeloencephalitis typically does not develop such severe signs over night however such clinical history is possible. The likelihood of either EEE or West Nile virus encephalitis is low in a well vaccinated horse yet not impossible! Diagnosis of encephalitis is dependent on serum testing and confirmation of EPM is dependent on testing of cerebral spinal fluid (CSF). Cerebral spinal fluid can be collected from two location including the atlanto-occipital (AO) joint space and the lumbo-sacral (LS) joint space. It was determined to collect CSF from the LS region. This option was chosen since it would be performed in the standing horse with moderate sedation. Collecting CSF from the AO site typically requires short term anesthesia and the ability of this horse to rise from recumbency was questioned. CSF fluid was collected and submitted for testing. The sample was positive and EPM was confirmed as the disease process in this horse. He is currently being treated with a variety of medications/supplements and the client is committed to treating for 4-6 months.

Read more about EPM @

http://www.aaep.org/health_articles_view.php?id=248

Stifle OCD!!

A yearling thoroughbred presented for sudden lameness and swelling around the stifle joint. The filly had been purchased several months prior from a select thoroughbred sale and repository radiographs were performed at the time of purchase. At the time of purchase, the filly was sound, there was no effusion of the stifle joint and there were no obvious radiographic changes noted in either stifle joint. When the filly presented for lameness, the stifle radiographs were repeated. Close inspection of the lateral trochlear ridge suggested irregular contours (yellow arrows inside blue box, Figure 2) of the trochlear ridge along the mid body region (Figure 1 and 2, blue box). Based on the radiographs alone, the filly was treated with intra-articular Hylartin and forced stall rest for 30 days.

Figure 1

Figure 2

Unfortunately, the filly remained lame after 30 days of stall rest and a follow-up exam included an ultrasound evaluation of the stifle joint. The ultrasound exam revealed significant changes along the lateral trochlear ridge which were not fully appreciated on the radiographic exam. In Figure 3, the lateral and medial trochlear ridge are displayed. The bony surfaces of the trochlear ridges appear as a bright white lines and the cartilage as  thin black lines that follow the contour of the bony surface. Any disruption of the bony surface/cartilage will appear as a mix of disrupted white lines and black pockets. In Figure 3, the image on the left is of the lateral trochlear ridge and there is clearly disrupted bone and cartilage along the bony surface.

Figure 3

In Figure 4, the lateral trochlear ridge is imaged in a longitudinal plane to assess the length of the defect. Irregular bone/cartilage appears to extend for several centimeters along the length of the trochlear ridge (yellow lines). The filly was referred for arthroscopic exam and a large bone/cartilage defect was identified on the lateral trochlear ridge consistent with a osteochondritis dissecans or OCD lesion.

Figure 4

Osteochondritis dissecans is defined as a disorder that results in cracks in the articular cartilage and underlying subchondral bone. The "cracks" and cartilage separation result due to lack of blood flow to the region resulting in avascular necrosis of the tissues involved.  This condition is considered in part a hereditary disorder AND nutritional.  Unfortunately OCD lesions are common in young horses that were bred for sport such as racing thoroughbreds, performance quarter horses, and warm blood breeds.  Some cases of OCD can be managed with surgical intervention however the OCD lesion in this filly's stifle was so large that there was no hope for soundness. This case is a good example of the benefit of multiple imaging modalities in diagnosing the source of lameness in the equine stifle.

Resolved Aspiration Pneumonia

Approximately 2 months ago a young warm blood gelding presented for a 4-6 month history of chronic coughing, bilateral nasal discharge, poly-synovitis, and failure to thrive. At presentation, the gelding was in poor body condition and there was a moderate amount of nasal discharge which consisted of mucus mixed with feed/hay. Auscultation of the thorax noted abnormal lung sounds, bilaterally.  As I reported previously, endoscopic exam revealed feed material within the larynx and trachea (Figure 1 and 2). The feed material was noted through out the entire trachea and a trans-tracheal wash revealed the presence of feed material and bacteria in the cranial ventral lung lobes! The gelding was diagnosed with dysphagia and aspiration pneumonia.

Figure 1

Figure 2

Based on the trans-tracheal culture results the gelding was treated with oral antibiotics for 30 days. In addition, he was treated with systemic anti-inflammatory medication and systemic anti-arthritic medication. Once the antibiotic treatment was started, the coughing episodes subsided but were not completely abolished. The gelding began to gain weight and for the first time was seen laying down to sleep and roll in the pasture! A follow-up endoscopy performed at the end of 30 days of antibiotics revealed feed material within the larynx (Figure 3) and an intermittent dorsal displacement of the soft palate (Figure 4). Mild to moderate ulcerations were noted along the caudal edge of the soft palate when displaced. At this point, we were not sure what was going to happen once we stopped treating with antibiotics however based on the continued presence of feed material in the pharynx, it was assumed that a recurrence of aspiration pneumonia was soon to follow.

Figure 3

After discussing the limited options with the owner, it was decided to pursue acupuncture as a potential source of treatment. Dr. Marilyn Maler was asked to examine the gelding and provide her expert opinion and treatment options. She immediately instituted an acupuncture regiment that was directed at treating the horse's difficulty with swallowing among other points of interest. According to the owner, the gelding's cough improved significantly and in a short period of time was completely absent! The gelding continued to gain weight and has been eating "normally" for over 4 weeks. A follow-up exam was performed 2 days ago and the gelding's condition has improved so dramatically that I did not even recognize the horse!  Endoscopic exam noted NO feed material in the pharynx and normal lung sounds!! The gelding has a long way to go but our conversation has shifted from when might it be time to "do the humane thing" to when might it be time to ride him!!  This case is a strong reminder of the benefits of acupuncture for treating chronic diseases and I wish to extend a special thanks to Dr. Maler for all her help!!

Figure 4

Final note: On the day of the most recent exam, the gelding was feeling so good that he played hard to get. So, he was enticed with several hand fulls of feed just prior to the endoscopic exam. This happens to be a crude method of detecting dysphagia in horses and the gelding passed with flying colors!!

Figure 5