Equine MLD - Lymphangitis case history

History

Cleo is a 20 year old bay Standardbred mare, who started life as a trotting racehorse. At the age of three she suffered a foreleg suspensory ligament injury, and was scheduled for euthanasia on the day she was acquired by her current owner. She recovered completely from this injury and remained healthy and was used as a riding pleasure horse without further incident until 18 months previously, when she suddenly developed a severe infection in her right hind leg, with massive swelling from her stifle to her hoof. The cause was unknown. She was treated for three weeks with 40cc Procaine penicillin, 20cc Gentamicin, diuretics and anti-inflammatories (all injected), and the leg was poulticed and iced. The swelling eventually subsided, but the skin on the distal leg became necrotic and sloughed off in large patches. A large drainage lesion appeared on the lateral fetlock from which pus drained, and proud flesh developed, which was treated with an antibiotic and Nolvasan cream, and bandaged and disinfected for four months until it began to stop draining. The hock remained somewhat swollen.

Nine months later Cleo relapsed with swelling in the leg. Vasculitis was suspected and she was put on antibiotics for two weeks. Two months after this she developed swelling in all four legs with serum seepage and was treated with antibiotics and anti-inflammatory medication.

On examination now, the hind leg had oedema extending from the coronet to the top of the gaskin. The swelling in the lower leg was firm, fibrotic and felt ‘brawny’ and structural features, i.e. cannon bone and tendons, were not individually palpable. Small fibrotic swellings could be felt in the plantar pastern. There was a large scar on the lateral pastern, and ~ 45% of the surface of the distal leg was scar tissue. The hock was swollen and indurated, and folds of oedemic tissue were visible to the fore between the annular ligaments, and her owner felt that the hock swelling was gradually increasing. There was a curb present, acquired during Cleo’s racing days. Her owner noted that when the lymphangitis was acute, pin firing scars became visible on various areas of the hock. The gaskin was swollen and firm to touch, and the Achilles tendon was not visually distinguishable.. When she moved it was evident that the leg could not be used normally, resulting in an apparent ‘twisting’ motion as the foot reached the ground, however she did not appear lame.

Cleo was in good condition but compared to photographs taken before the illness, appeared to have lost muscle tone, and her owner said that lately she had seemed listless.

Treatment

It was decided to treat Cleo with combined decongestive therapy. Cleo was moved to closer premises, and housed in a half roofed end pipe corral with shavings bed and an empty corral next door as she is not over fond of other horses but could still see others around her. Photographs and measurements of the leg were taken on the first and then initially every second day. Intensive combined decongestive therapy (CDT) was started, involving manual lymph drainage (MLD), compression bandaging using short stretch bandages (Rosidal K) and 100% cotton wool padding. Duct tape was used to secure the bandages. Cleo’s hooves were oiled and moisturising lotion was applied as required prior to bandaging. Cleo was then exercised in the bandage in walk and trot for a minimum of 30 minutes. The intention was to repeat this treatment every day, until oedema reduction measurements became stable.

However, what had not been anticipated was that soon after treatment started, Southern California would experience its worst rainstorms in decades. These was extremely heavy and lasted for days, resulting in floods, landslides and considerable damage to property. We were not immune, the equestrian centre was extensively flooded, and the canyon leading to Cleo’s home was subsequently blocked by a mudslide. Cleo’s treatment had to be adapted as we could not lead her out to be exercised in the flooded surroundings without her bandage immediately becoming soaked and useless, and this did slow treatment down.

It is important at this point to recognise the contributions of Dayle, who assisted me and exercised Cleo every day despite the atrocious conditions, Georgina who also assisted when not tirelessly inventing ways to protect Cleo from the elements and kept her comfortable and dry, and her highly conscientious owner who is very committed to Cleo’s treatment and welfare.

Treatment diary

Days 1–6: CDT is performed every day. By day 2, oedema is visibly reduced, the pastern profile is less convex. The distal leg tissue is still firm but softer, the hock oedema is reduced and the Achilles tendon is now palpable. Cleo’s movement is freer and her demeanour cheerful. Fibrotic tissue surrounding the curb is treated. Oedema reduction and tissue softening continues over the next two days and the fetlock/pastern no longer appears to ‘twist’ when Cleo walks. On day 5 the gaskin measurement has reduced and the bandage is looser above the hock and has slipped slightly. Overall leg measurements are down. The distal leg tissue is still ‘brawny’, but now pits with pressure. Cleo is walking well and trotting readily in the compression bandage. On day 6 the pastern is softer and the large area of scar tissue at the fetlock is more mobile. Gaskin oedema continues to reduce and the achilles tendon is now visible. The SDFT is now detectable to touch.

Days 7-10: Everywhere is flooded and the storm frequently limits exercise. As a result, oedema measurements are up and down, though continuing overall to reduce slightly. On day 9 we attempt to move Cleo into a dry box but it is dark and there is no view out. She is distressed by this and will not settle, but does so immediately on return to her corral. To avoid soaking the compression bandage Cleo is now exercised before CDT treatment in a short stretch bandage applied to the distal leg.

Days 11-13: Cleo’s corral is taking the brunt of the appalling weather. We fix tarpaulins to the corral fences and protect the compression bandage with a black plastic bin liner. On day 12 there is a slight break in the weather and she can be exercised in the compression bandage, otherwise she continues to be exercised before treatment in the single bandage. By day 13 there is no real change in the volume measurements but the cannon bone and tendons can now be distinguished on the medial side of the lower distal leg and the tissue is much softer.

Days 14-22: It is very important that Cleo can progress now without continued CDT and that she is fitted with a supportive stocking (Debo Kompressionsstrumpf) which will be trouble free when she returns home, to help maintain the oedema loss and encourage reduction of fibrosis. During this time we find that a stocking which suits her lower leg constricts the gaskin area even with quite light pressure, producing swelling, and that the size which suits the gaskin does not support the lower leg adequately. This is solved by inserting a soft elastic gusset into the top of the smaller size stocking. Cleo’s owner supplies her tack and she starts ridden exercise. The stocking is taped to her hoof to prevent it riding up and constricting the coronet, but it shows no inclination to do this, and is taped at the top to the leg to prevent it rolling down. During this period the stocking does slip a couple of times overnight and the resulting constriction causes some swelling, which resolves quickly with CDT. Cleo has a thick winter coat and clipping a band of hair where the stocking is taped greatly improves adhesion.

By day 22 the stocking is staying in place overnight and when Cleo is exercised. The volume reduction remains stable and the distal leg tissue is pliable. Videoing Cleo while she is being ridden shows that she is moving freely and that her action is level. Cleo is collected by her owner and returns home.

Results

At the end of the treatment, there was an oedema reduction of 38.5% in the distal limb.

Changes in measurements (cms) included:

	healthy leg	pre treatment	post treatment
gaskin	43	46	43
hock	42.5	52	48
mid cannon	23	29.6	28
fetlock	30.5	35	33.4
pastern	23.5	36.5	26


pre treatment	post	pre treatment	post

Maintenance phase

Cleo currently wears the support stocking 24 hours a day, and is either ridden or lunged actively for an average 45 minutes daily. Her owner was shown simple MLD techniques to use with Cleo, and a method of brushing her to encourage lymphatic transport.

The stocking came down overnight on one occasion resulting in oedema above and below where it had settled below the hock. CDT was applied and the next day the oedema had resolved. We came to the conclusion that on this occasion and on a previous time this happened, the stocking, which was only just long enough for Cleo, had been pulled up too high and the extra stretch had encouraged it to come down. Cleo’s owner has replaced the duct tape with elastic adhesive tape (Elastikon) and it has not happened since. However, If it does happen again, the advice is to replace the stocking and exercise Cleo, to bring the swelling down. The manufacturers were approached and have since supplied longer length stockings for Cleo.

Notes

Cleo’s severe attack of lymphangitis had clearly caused considerable inflammation and damage to the lymphatic vessels in the affected leg and they had not been able to make a functionally adequate recovery, allowing protein rich fluid to accumulate in the tissues, which in the distal leg had become fibrotic. The considerable scarring to the distal leg also contributed to the resultant lymphoedema; the generation of new lymph vessels and formation of links between them plays an important role in wound healing, but lymphatic vessels cannot regenerate where established scar tissue is present. Oedema in the hock joint was reduced by treatment, but it remained indurated and larger than normal. The pin firing to the hock, although done many years ago, would have created internal adhesions and scar tissue, obliterating some lymph vessels and preventing others from functioning. Remaining ones would have been forced to work harder and over time would have become increasingly strained. When the lymphangitis occurred it may have been ‘the final straw’ and the lymphatics could not recover enough to provide adequate lymph transport. Perfusion of the tissues with oxygen and other nutrients would be diminished as would the removal of toxic waste products. Because of compromised immunity, the leg would be vulnerable to repeated infection, with likely further damage.

Oedema reduction is therefore a measure of success in the treatment of lymphoedema, but equally, improvement to the health of the tissue is vital. Manual lymph drainage can promote the movement of lymph through unaffected collateral vessels, and if fibrotic tissue is softened and broken down, both blood and lymph circulation improve. In horses it can result in significant improvement to movement, returning them to useful working lives.

Movement is important to the adequate function of the equine lymphatic system, and this was very evident in Cleo’s treatment. The support stocking provides a correct level of pressure to the walls of the lymphatic vessels allowing them to function more efficiently especially during exercise. In human treatment, use of a support garment frequently results in continued oedema reduction and softening of fibrosis in the months following intensive CDT treatment. Whether this will happen with Cleo is difficult to predict, not least because of the scar tissue, but if she maintains her current results she should be less vulnerable to repeated infection than had she not been treated. Pressure on her joints will be relieved and long term wear from the altered movement avoided.

To date, Cleo is active and healthy. During the CDT maintenance phase, further MLD or CDT treatments depending on the stage of the condition can be helpful, and hopefully next time I am in Southern California there will be opportunity to meet up again with Cleo and offer this if required.