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Pain Management: Musculoskeletal Pain

This causes gram-negative organisms to die and release vasoactive endotoxins. Rumenitis is frequently associated with ruminal acidosis. High levels of histamine in the blood have been found in the early stages of the disorder. It is probable that subacute ruminal acidosis is one key factor in development of laminitis, because managing subacute ruminal acidosis SARA helps control the incidence of subclinical laminitis. Contemporary thinking is that as production levels increase, cows become more sensitive to risk factors.

A risk factor in this case is any physical insult causing stress. This probably leads to the release of bioactive messengers into the bloodstream. One important risk factor is trauma; many clinicians are convinced that hard flooring is equal in importance to nutritional problems. Care must be taken when dry cows and heifers are introduced to concrete after being accustomed to soft flooring.

Although the release of biologic messengers into the bloodstream is known, identification of the agents that play a part in laminitis is ongoing. Epidermal growth factor EGF receptors are present in the basement membrane of the corium of the claw. EGF is liberated in large quantities from the GI tract when it is damaged eg, rumenitis and could be involved in the pathogenesis of laminitis. In addition to its mitogenic effect, EGF can inhibit the differentiation of keratinocytes in vitro.

Inhibited differentiation of keratinocytes of the hoof matrix is a dominant morphologic feature in the early stages of laminitis. This supports the hypothesis that laminitic histopathologic changes result from an inadequate regulation of gelatinase activity, resulting in selective degradation of basement membrane components due to failure of the basement membrane—epidermis attachment.

More recent investigations have studied the role of matrix metalloproteinase MMP activity in the pathophysiology of laminitis. It is not known which endotoxins are involved in releasing MMPs.

It is known that MMPs play some part in allowing collagen fiber supporting the distal phalanx to stretch. During the peripartum period, hormones such as relaxin are generated. Correct management of nutrition around calving is critical. In early calving heifers, it is possible growth hormones could have a complicating role. Whatever the biologic messengers, they appear to affect two different types of tissues: This results in two distinctly different pathologies. The pathophysiologic process associated with compromised horn production starts when vasoactive toxins or other biologic agents reach the corium.

Arteriovenous shunts may be paralyzed, pressure inside the claw rises, and the walls of the vessels are damaged. Blood or blood fluids escape and soak into the claw horn, staining it either pink or yellow. Mural thrombi form, reducing blood flow and causing oxygen deprivation and an insufficient nutrient supply to the keratin-producing cells. Thrombus formation is a characteristic feature of laminitis. The resulting horn is soft and prone to damage, infection, and scar formation.

The second pathophysiologic process involves MMP release and stretching of the collagen fibers of the suspensory apparatus of the digit. Collagen fibers originate in horny corrugations lamellae on the inner surface of the hoof wall and insert into those areas of the distal phalanx that have no periosteum.

Thus, the pedal bone is "suspended" from the wall of the hoof. Ultrasound of the proximal suspensory should be critically compared with that of the other limb, remembering that bilateral lesions do exist.

Nuclear scintigraphy can help detect osseous injury at the proximal suspensory attachment, but negative scintigraphic images do not exclude the presence of PSD. MRI is also extremely useful to detect subtle changes in the proximal suspensory ligament that may not be visible or conclusive with ultrasonography. In addition, MRI allows accurate examination of the osseous structures adjacent to the suspensory ligament metacarpal bones and distal carpal bones. Horses with chronic PSD may require a longer rehabilitation program or adjunct therapy NSAIDs, shockwave, regenerative therapies to return to consistent work.

This is principally an injury of racehorses. Injuries usually affect the forelimbs of Thoroughbreds and the forelimbs and hindlimbs in Standardbreds. Soreness on palpation of the forelimb suspensory ligament is quite common in horses with lameness associated with a more distal limb problem; however, structural abnormality of the ligaments is only rarely identifiable ultrasonographically. Clinical signs vary and involve enlargement of the ligament, local heat, swelling, and pain.

Diagnosis is usually based on clinical signs and can be confirmed ultrasonographically. Treatment is aimed at reducing inflammation by systemic NSAIDs, hydrotherapy, and controlled exercise.

Shockwave therapy, platelet-rich plasma, and stem-cell therapy have also been used for suspensory body lesions. This relatively common injury is seen in all types of horses in forelimbs and hindlimbs. Usually only a single branch in a single limb is affected, although both branches may be affected, especially in hindlimbs.

Foot imbalance is often recognized in affected horses, and this may be a predisposing factor. Clinical signs depend on the degree of damage and the chronicity of the lesion s and include localized heat and swelling. Swelling is often due to local edema of the affected branch. Pain is usually elicited either by direct pressure applied to the injured branch or by flexion of the fetlock. Lameness is variable and may be absent. Diagnosis is based on clinical signs and ultrasonographic examination.

Radiographic examination should also be performed to evaluate the attachment of the suspensory branch on the proximal sesamoid bones. Low 4-point diagnostic analgesia as well as intra-articular analgesia of the fetlock joint varying degrees based on the location of the branch injury improves lameness.

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