Treating the Equine Athlete

Dice is a really handsome guy. As he trots up and down the main corridor at Cummings School’s Hospital for Large Animals—the sound of his hoofs echoing off the cinderblock room—several vets, techs and students stand at one end admiring the piebald steed. To the untrained eye, Dice looks young and vigorous, in tip-top shape. But Kirstin Bubeck, a veterinarian specially trained in equine surgery as well as sports medicine and rehabilitation, sees a lot more than most.

Horses are stoic by nature and tend to mask their pain. It takes years of training for a veterinarian to learn to read the signs and make an accurate diagnosis: the slight lift of the head to shift weight off the injured limb, or the spasming of a muscle when a sore spot is palpated. Horses, after all, have four legs, and can do all kinds of clever things to compensate for an injury.

In a German-accented voice, Bubeck asks the handler to take another 65-foot lap. She studies the animal’s movements with a keen eye. “Yes, I see that he has a mild lameness in the left front limb,” she observes as Dice (short for Tumblin’ Dice) makes his way toward us, his gorgeous silky white mane and forelock shimmering with every step. For my part, I still don’t see a thing. “Let’s take him out to the ring,” Bubeck says, “in order to further evaluate him.”

The 15-year-old Gypsy Vanner from North Stonington, Connecticut, is an unusual sight. Because this equine line has only been in the United States for a couple of decades, few Americans know about these magnificent draft horses, originally bred by British Romani to pull their colorful caravans.

On average, Gypsies are about 10 inches shorter than Clydesdales, but they’re plenty strong enough to haul loads. They’re valued for their beauty and family-friendly disposition, critical to their role within the Romani culture.

Jen Marshall was there the day Dice was born. “He’s our first baby, so he’s got a place in our hearts.” Photo: Gale Zucker

Dice spends most of his time with several other Gypsies on Jeff and Jen Marshall’s gentleman’s farm, financed by Jeff’s two shipyards on the Mystic River. The couple uses their Gypsies for riding and to draw a collection of vintage carriages (some from the 1800s) along local trails. Occasionally, they pack up a trailer and head for Acadia National Park and its scenic carriage roads along the Maine coast. Jen, a seasoned horsewoman, says the animals love the trailer and love to be worked.

To Jen, Dice is family. She was right there when he was born, which wasn’t easy to pull off. She spent several days closely monitoring his pregnant mother, Vanna, because she knew from experience that the big event can happen within minutes, often when no one’s looking. One time, while waiting for another horse to be born, Jen ran out to grab coffee and came back to find a spindly foal prancing around the barn.

“He is a pretty special guy,” Jen says of Dice. “He’s our first baby, so he’s got a place in our hearts. And even on the day he was born, he was doing somersaults in the stall, even though he was just an hour old. As he got older, he was always the one at the gate first to greet us, always pulling our hats off and just being silly like that.”

Athletes of Olympic Caliber

So when Dice slipped on the ice and began limping, Jen got worried. After consulting with her local veterinarians, Matt and Ashley Kornitowski of Twin Pines Equine, she decided to make an appointment at Cummings School.

The Hospital for Large Animals is part of the Cummings Veterinary Medical Center at Tufts, situated among the rolling hills of North Grafton, Massachusetts. It opened in 1978, and since then, the vets here have treated newborn giraffes, lame llamas, a wallaby with a neck fracture and a warthog with arthritis. But mostly they treat horses.

Forty years ago, thoroughbreds from Suffolk Downs kept the veterinarians here busy. Those equine athletes presented the usual horse health problems, but they also challenged Tufts clinicians with sport-related complications. The veterinarians became experts in addressing the muscular and skeletal issues that can impede a racehorse’s performance, and eventually established an equine sports medicine specialty.

But then people stopped going to the racetrack, purses shrunk, and the animals were considered less valuable. So it followed that for owners, diagnosing and treating racehorses often made less financial sense than putting them out to pasture. To meet the needs of the equine industry, Cummings School had to shift gears.

That wasn’t difficult. Among the approximately 60,000 horses in Massachusetts alone, plenty of equine athletes compete in the most demanding equine sports: dressage (often called horse ballet), hunter/jumper events (which involve moving through courses and jumping fences), and three-day eventing (cross country, dressage and show jumping).

In time, Cummings School developed a thriving practice treating these athletic equine standouts. In fact, some of the horses that come to Tufts are Olympic caliber. Keeping the equine athletes in prime shape demands a bevy of supplements and a team of specialists, including trainers, farriers, saddle-fitters and chiropractors—and, of course, first-rate veterinary care.

Skilled ambulatory veterinarians treat this sport-horse population at the horses’ barns. With cutting-edge technology at their disposal, including sophisticated ultrasound machines tethered to laptops with proprietary software designed specifically for equine doctors, ambulatory veterinarians can identify and treat a wide range of conditions.

Occasionally, however, it’s helpful to enlist a team of specialists with access to advanced imaging technologies such as MRI, CT, nuclear scintigraphy (a diagnostic test that captures two-dimensional images of organs and tissues), high-definition ultrasound, a treadmill with dynamic endoscopy capabilities, and a state-of-the-art surgical unit.

To complement the ambulatory care that private vets provide to this demanding population, Tufts built a world-class sports medicine program, headed by veterinarian José M. García-López, an orthopedics expert board-certified in surgery and sports medicine and rehabilitation. García-López received his veterinary degree at the University of Pennsylvania and honed his interest in equine sports medicine and orthopedics during his summer externships as a student back in his native Puerto Rico, where he worked at a racetrack under the mentorship of veterinarian José M. García-Blanco. “They’re amazing athletes,” he says, “but they can be frail.”

Complex Anatomy

Among equine athletes, potential for injuries abounds. For example, dressage horses suffer from inflammation of the tendons and ligaments in their back legs more frequently than other horses, because the sport demands more hind leg work than other events. Fatigue can lead to muscle, tendon or ligament strains.

There are respiratory conditions, like dorsal displacement of the soft palate—a common condition in which the horse’s soft palate flips over the epiglottis, making it difficult to breathe during rigorous exercise. An ill-fitting saddle can cause spinal injuries, which can lead to lameness.

Horse anatomy is also complex. Consider their legs. Unlike humans, horses have thick femurs and tibias. Their ankles are halfway down the leg, where you’d expect a knee in a human. The rest of the horse leg is built like a foot, a very long foot that ends in a hoof instead of toes and contains several joints that can cause problems, beginning at the coffin joint, which lies inside the hoof.

In the equine sports medicine and surgery service, specialists José M. García-López and Kirstin Bubeck follow their patients from diagnosis through treatment and rehab. Photo: Ken Richardson

As García-López continued developing the school’s Issam M. Fares Sports Medicine Program, he recognized that quality of service was as important as quality of care. “It’s a very demanding clientele,” he says. Many of the owners are serious hobbyists strongly bonded with their mounts. That’s why García-López and Bubeck, who joined Cummings School in 2014, reimagined the equine sports medicine and surgery service that same year. The service now operates more like a private practice, with two dedicated doctors who follow their patients all the way through rehab.

But the Hospital for Large Animals—cavernous and constructed of cinderblock—hadn’t seen any physical updates since it was built in the early 1980s. And it lacked a ring where riders could perform the moves in the saddle that reveal their horse’s lameness. That was been a problem because, just as your mechanic needs to get your car on a highway in order to hear that rattle that shows up only at 60 mph, so your vet needs to see your horse exercising in a proper ring environment to see firsthand why he’s landing funny during that tricky dressage move.

All the Comforts of Home

So two years ago, Cummings School’s equine vets made a passionate—and convincing—case for the construction of a regulation-size indoor ring and a barn with all the comforts of home. The school started a capital campaign, and immediately an anonymous donor offered to support the project.

With three cupolas and big barn doors, the new 14,000-square-foot complex will look more like what the horses know. There’s the ring, where horses and riders can recreate the exercises that reveal injuries, and also a conference room, tack room, holding stalls and exam rooms. The goal is to make everyone—horses and clients alike—feel safe and at home.

Back in the main corridor at the Hospital for Large Animals, Jeff and Jen Marshall and the Cummings team are getting ready to watch Dice walk and trot in the outdoor run so that they can see him turn. The group moves to one end of the corridor and, with the push of a button, an enormous garage door rolls up. Outside, the weather is miserable. It’s pouring.

High up on a hill, there’s a riding ring where the vets can “lunge” Dice—put him on a long lead and ask him to run in circles to better observe his gait—but no one wants to venture that far in the rain. “This is why we need an indoor ring,” Bubeck says, grabbing her jacket and heading out as everyone else huddles just inside the door to watch her work.

Dice doesn’t mind the stormy weather, but he clearly doesn’t like “bending” to the right, another way to describe trotting in a tight circle. As his handler maneuvers him in this direction, the limp becomes pronounced, and those watching wince in unison. Dice is in pain. It’s obvious that his right front leg is the problem.

Getting to the Cause

But is it a joint issue? A tendon issue? Or could it have something to do with bony growth on his leg, called an exostosis, that’s been there for years? When a horse develops a lameness, vets go through a process of elimination, numbing joints higher and higher on the leg in an effort to find out which one is the culprit. This takes time and patience. And sometimes the root problem isn’t in the leg at all.

Bubeck decides to turn to more sophisticated diagnostic tools to find out what’s bothering Dice. Back inside the hospital, she asks her colleague, veterinarian Kate Chope, another equine sports medicine and rehabilitation specialist and one of the few specially trained equine ultrasonographers in the country, to take a look with the ultrasound machine.

A tech clips Dice’s beautiful feathers—the long, thick hair on his lower leg—on the injured leg, apologizing profusely to Jen as she does it. That’s OK, Jen says, it’ll grow back. Getting a good image of the tendons and ligaments through the horse’s skin with ultrasound isn’t easy—Dice’s skin is very thick—and Chope spends a lot of time trying see what’s going on in there. Behind her, a large LCD screen shows what she’s seeing.

Chope narrates where she is on the leg and calls attention to things that concern her. Dice has been sedated so that he doesn’t move too much while she works. The Marshalls patiently stand by while Dice’s lower lip droops and his eyes slowly close.

The ultrasound reveals some inflammation in a ligament, which Bubeck suspects has something to do with his lameness. She uses a needle to inject that area with a local anesthetic while a Tufts team member feeds Dice a constant supply of horse cookies to distract him from the vet performing the procedure. The lidocaine takes about 15 minutes to activate, so the whole team—Bubeck, her assistants, two Cummings School veterinary students and the Marshalls—discuss possible next steps if this doesn’t work. Finally, Dice takes another lap, but his limp hasn’t changed. Translation: he’s still in pain, and that ligament wasn’t the problem.

To test a hunch, Bubeck injects more anesthetic, this time around Dice’s bony growth. When he takes a lap again, the limp magically disappears. The exostosis, Bubeck concludes, is causing discomfort. To make sure that the soft tissues surrounding the exostosis weren’t injured during Dice’s slip on the ice, Bubeck takes a radiograph of the area, but the X-ray picture reveals that all is fine. She decides that surgically removing Dice’s growth is the best course of action.

Dice stays overnight at the Hospital for Large Animals, and the Marshalls return to their Connecticut farm. The following day, Bubeck performs surgery to remove the exostosis. After one more overnight, Dice gets in the Marshalls’ trailer and rides back home. Every few days, Jen changes the bandages on Dice’s leg to monitor how it’s healing, and sends photos of the recovering area to Bubeck, so that she can see the surgical area and ensure that it’s not infected. Two weeks later, the Marshalls’ local vet removes the sutures.

Five weeks after Dice’s surgery, Jen says, “He’s in a small paddock now, no bandages, and everything looks terrific.” Following Bubeck’s recovery plan, the Marshalls walk Dice twice a day, like a pup on a leash. Jen says that they’ll start riding him soon, at a walk, and trot him about a month after that. But right now, they’re keeping handsome Dice sedentary, which happens to suit their “barn clown” just fine.

“He’s very happy not having to work right now,” Jen says. “He just stands around eating. For him, it’s a nice little vacation.”

Rachel Slade is a freelance writer in Brookline, Massachusetts.