Horse owners across the globe are looking for the most athletic equine to compete. Which horse can jump the highest? Run the fastest? Go for the longest?
It's important that when we consider purchasing an animal for competitive needs, we need to do our due diligence. As a horse owner, it is our duty to advocate for our animal so they can achieve their very best performance and stay happy and healthy in their daily routine(s).
However...
We've all seen it: a horse sale ad with a mention of "some maintenance required." When did it become normal for "maintenance" to be code for regularly scheduled invasive medical procedures?
Any sale ad that mentions "some maintenance required" should be your red flag to you that this horse is being pushed past its limits and needs consistent pain medication to continue to compete.
The demands for athletic performance are daunting, but at what point do we ask: when is enough, enough?
Steroid injections DO stop pain, they DO NOT stop the cause of the pain
I very much like the analogy of tying a piece of string or floss around your finger. Imagine you tie this string around your finger gently day one, but every single day, your job requires you to tighten the string just a little bit further.
The tight string over time would: impede blood flow (which will cause swelling), restrict range of motion (which will cause cramping in the muscles), and dampen nerve sensation (which will cause numbness, tingling, or some other variation of pain.)
Will sticking a needle and injecting a bunch of drugs into the tip of your finger help? Maybe, if you like to not feel your finger. With this approach, you could push through your day to day because there wouldn't be any "pain."
But, what will actually fix the problem?
The real fix involves removing the cause: the tightened string!
Musculoskeletal pain is much the same.
Although I do not mean to simplify the complexity of the body, musculoskeletal and joint pain are often due to repetitive tasks that put strain on certain structures (muscles, bones, or tissues) of the body. Due to increased stress over time, these structures break down / become inflamed. The more you perform repetitive tasks, the more you "tighten the string."
Here is a simplified drawing of the cascade of inflammation. There's a lot of big words in this chart... and there is also two classes of drugs depicted with their respective mechanism of action.
What's important from this drawing: steroids block ALL inflammation pathways at the very beginning of the cascade.
You may be asking: well, isn't that a good thing?
Maybe for acute trauma where the body is producing too much inflammation.
But otherwise (on a more chronic and gradual scale)? Not so much.
When cells break down, inflammation is a signal to the body that there is DAMAGE occurring. The brain needs to receive this signal so it can either A. tell us to stop or B. trigger healing mechanisms. However, if we block these signals, the long term the ramifications could be irreparable.
Imagine your joint cells as children...blindfolded and being told to just keep swinging at the proverbial piñata, meanwhile the "supervising adult" of a brain is being given margaritas. This is essentially what happens to the joints by constantly playing cover up with pain medication. Instead of 'candy in the piñata', we have the aches and pains of chronic joint damage about to be released and the brain is incapacitated and without the ability to tell the body to stop.
(This also doesn't mention the various other body processes that rely on these chemical signals to maintain a sense of balance.)
Steroid joint injections do work, but they are a temporary solution
Say your horse does have severe pain and you do want to proceed with joint injections.
You may be wondering: How long does a joint injection last? How often will you have to do them?
Many research studies have been done on the topic. I have provided a cursory view below:
In this article, a sample of 27 horses that were positive with nerve blocking in the front fetlock joint were given either a placebo injection of saline or a joint injection of hyaluronic acid.
Lameness scores between the control group and treatment group were not statistically significant, flexion tests were only slightly better in the treatment group, and measured pain and swelling post procedure were about the same. An owner interview was also conducted, and 3 months post treatment, 67% of the horses were rated as able to go back to their previous level of exercise.
This study suggests to me that administration of steroids simply swept the problem under the rug. Symptomatically, 70% of horses seemed better to their owners... but almost all of them, upon examination, still showed evidence of a problem (swelling, pain on flexion tests) in comparison to placebo.
The article conveniently did not make clear which of the 70% of "improved" horses were placebo and which were in the treatment group.
So, initially, when you read this study... you would think 70% improvement is pretty good, right?
However, the article is concluded with the statement "a steroid injection is no better than a saline injection for the purposes of reducing lameness in horses with synovitis or mild osteoarthritis."
Because, folks... when rating improvement, we have to consider FUNCTION objectively. We cannot just take an owner at their word.
Here is another study done on 51 horses with osteoarthritis of the lower joints of the hock.
This study found that 58% of the horses improved initially, but that 90% of them had relapsed by about 56 days later. Of the owners that completed a telephone follow up (34), only 38% of horses were rated as having a positive outcome, whereas 62% were reported as having a negative outcome.
For the reader, this seemingly suggests that horses will need follow up injections every 2-3 months to achieve statistically relevant symptomatic improvement.
For me, with a 60+% negative outcome rate, you may as well flip a coin on whether or not joint injections will make an improvement for your horse.
This study was interesting as it compared steroid alone as well as steroid cocktail (steroid + hyaluronic acid.)
80 horses were included in this study and were measured for improvement at 3 weeks post procedure with an additional owner interview at 3 months.
After 3 weeks, 87.8% of the horses that got steroid injection only objectively shown to be better, while only 64.1% of the horses that got the combination were better.
However, the older the horses were, the less likely treatment was to be successful. Horses over 13 years of age had a statistically significant reduced success rate for treatment.
And the most depressing finding: after 3 months post procedure (regardless of which drug used), only 50% of horses had returned to their previous level of performance.
Draw your own conclusions from this small sample size of research studies. Yes, I may be cherry picking, but based on what I can see, joint injections help horses about 50-65% of the time and the positive effects usually don't last longer than 3 months at a time.
The risk may outweigh the benefits
Do you know that epidural (spinal) steroid injections for humans are not approved by the FDA?
(https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-label-changes-warn-rare-serious-neurologic-problems-after)
This is due to a plethora of life changing side effects and low statistical efficacy.
Here are the warning labels if you'd like to review:
Methyl-prednisolone
Triamcinolone acetonide
I'm not judging a horse owner that wants to do anything possible to get their horse out of pain. I think that is a noble cause.
But, all medications and all medical procedures come with risk.
For your animal, you need to have a candid conversation with your vet about what risks you are willing to undergo to achieve a certain result.
Remember, steroids have a systemic effect. Use them sparingly.
For example: injectable steroids have been shown to cause bone loss over time, due to their inhibition of osteoblasts. Steroids have also been shown to negatively effect healing, as they block certain protein synthesis.
This begs the question: are you willing your horse to gradually lose their bone density and possibly suffer from a completely avoidable fracture?
Here is a (human) study with a conclusion on steroid injections that mirrors my own personal opinion:
"Although the benefits for epidural steroid injections may include transient pain relief... the multitude of risks attributed to these injections outweigh the benefits."
There are safer alternatives with less side effects
Think of an olympic level (human) athlete. What does their daily routine look like?
This athlete may have the following:
Carefully crafted anti-inflammatory diet or meal plan.
A work out plan with goals to be achieved.
Warm up routines.
Cool down routines complete with stretching.
Regularly scheduled body work (such as acupuncture, massage, chiropractic, physical therapy, etc)
Performance enhancing supplementation.
Custom fitted equipment.
And maybe more!
Let's compare this to your horse.
If we are asking our horse to perform at their best, but not strategically enabling them to have all the tools they need to succeed... we are actually setting up our horse for failure.
After all, you cannot expect a car to keep driving if you never do oil changes or tire rotations. So why do we expect this from our horses?
I understand maybe finances could be a concern, but regularly scheduled hands on care is like making regular deposits in an investment account VS repeatedly making withdrawals from a savings account. One accrues value, while the other will eventually bottom out.
There are safer options available! Leave joint injections as a very last resort.
Do you best to find the cause of the inflammation and fix it, then the need for injections will dissipate.
Ask your vet about other options that are available... and never be afraid to get a second opinion.
Your horse deserves to have a long, happy, healthy, sustainable, and COMFORTABLE career.
*This blog post is based on my opinion and should not constitute, nor should it replace, veterinary advice. Please ask your vet about joint injections and make an informed decision based upon what is right for you and your animal.*
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