Recovering from Sesamoiditis

Q. Two weeks after my sister bought a 10-year-old gelding, he started head-bobbing at the trot. Many veterinary exams, farrier visits, and six months later, we found sesamoid problems on both forelimbs. Can the sesamoid bones be removed? The veterinarian said his tendons are putting pressure on the sesamoid bones, which is resulting in small fractures and weakening the tendons (eventually, they will be severed). The rear of the fetlocks have been blistered several times (the vet said this increases circulation and promotes healing), then hyaluronic acid injections were given in both front legs. We also changed his shoeing, added a pad, and brought the breakover back toward the heel. The horse didn't limp for a couple of days, but now it's worse than ever. He's a quality horse and we really want to help him. Any suggestions?

Marian Gregor, Chelsea, Mich.

A. The proximal sesamoid bones in the horse are two small bones sitting at the base of the cannon bone in back of the fetlock joint. They are critical components of the suspensory apparatus that supports the horse's distal limb. The suspensory ligament originates from the bottom of the carpus (knee) or tarsus (hock) and runs down the back of the cannon bone, attaching to the top of the proximal sesamoid bones. The distal sesamoidean ligaments originate from the bottom of the proximal sesamoid bones and run down the back of the pastern, attaching at the back of the long and short pastern bones. The suspensory ligament, proximal sesamoid bones, and distal sesamoidean ligaments make up the suspensory apparatus of the fetlock joint and work together to prevent overextension of this joint when the limb is fully weight-bearing. Because the proximal sesamoid bones are integral in the suspensory apparatus of the distal limb, they cannot be successfully removed.

Sesamoiditis refers to pain associated with the proximal sesamoid bones. It often results from inflammation at the interface of the suspensory ligament and distal sesamoidean ligaments with the sesamoid bones. It is caused by unusual strain to the fetlock joint. It is most often seen in racehorses and jumpers, but it can be seen in any breed or discipline of horse.

Signs of sesamoiditis include lameness that often worsens when the horse is worked on hard surfaces. It can be exacerbated by fetlock joint flexion tests. There may be heat, swelling, or firm thickening around the fetlock joint, and the horse might be sensitive to palpation of the sesamoid bones.

A definitive diagnosis of sesamoiditis is made by taking radiographs (X rays) of the fetlock joint and sesamoid bones. Radiographic changes include increased size and number of vascular channels within the bone, calcification (hardening) of soft tissue structures surrounding the bone, proliferative bony production on the sesamoid bones, and avulsion (separating) fractures at the attachments of the suspensory ligament and distal sesamoidean ligaments to the sesamoid bones. If sesamoiditis is diagnosed based on radiographs, it is important to also ultrasound the suspensory ligament and distal sesamoidean ligaments to assess any damage they might have.

Treatment goals include reducing inflammation in the sesamoid bones and fetlock joint. Rest is crucial until the horse is sound at the trot, at which point he can be built back up slowly. In the initial stages of inflammation, alternating hot and cold therapies, and poultices on the fetlock, will help reduce inflammation. Non-steroidal anti-inflammatory drugs such as phenylbutazone work systemically to decrease inflammation. Intra-articular treatment of the fetlock joint with hyaluronic acid will locally reduce inflammation in the joint.

Correct shoeing is critical to managing sesamoiditis. Some horses do well in egg bar shoes with squared toes and a wide roll or bevel. Having the toe pulled back and setting the shoe back will ease breakover, thus reducing stress on the suspensory apparatus. Other therapies such as blistering and extracorporeal shock wave therapy have been used with varying degrees of success.

Horses often need up to eight months of convalescence before returning to full work. Prognosis varies greatly depending on severity and whether surrounding ligaments are affected.

Jerry Black, DVM, and Natasha Lefkowitz, DVM; Pioneer Equine Hospital, Oakdale, Calif.

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