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EQUINE PRACTICE Manual palpation

of the anatomical
landmarks followed
by ultrasonographic
investigation are helpful
when managing acute
stifle injuries in horses

Diagnosis and management of

acute stifle injury in adult horses

LAMENESS associated with the stifle is relatively infrequent in horses. However, a number of conditions
affecting the stifle region can cause acute lameness and need to be recognised. Stifle injuries are often
the result of direct trauma such as kicks from other horses or failure to successfully clear fixed fences at
speed, but can also result from abnormal rotational forces acting on the joint. The degree of lameness
usually, but not invariably, reflects the severity of the damage. Some degree of soft tissue swelling
may develop, although the absence of detectable swelling does not preclude severe damage. When
confronted with suspected stifle injuries in the field, careful palpation of the area is an important part
Richard Reardon
graduated from the of the clinical investigation and requires good knowledge of the anatomy and function of the joint. This
Royal Veterinary article describes the basic anatomy and function of the stifle, reviews the diagnostic techniques that are
College in 2004
and then worked
frequently used to investigate acute stifle injuries and presents some of the more common causes of
in mixed practice acute lameness associated with the stifle region.
in Warwickshire.
After an 18-month
internship in
Newbury, he ANATOMY
undertook a
residency in large
animal surgery The stifle is the largest and probably the most complex
at Glasgow. His joint of the horse. The osseous structures of the stifle
research interests are
surgical treatment include the proximal tibial plateau, with the head of the
of cervical vertebral fibula on its lateral aspect, the distal femoral condyles,
and upper airway
the femoral trochleae and the patella.
disease in racing
The tibial plateau articulates with the femoral condyles
via the medial and lateral menisci (femorotibial joint),
and the patellofemoral groove (located between the larger
medial and the smaller lateral trochleae) articulates with
the patella (femoropatellar joint).
The femorotibial joint is divided into medial and
lateral compartments by separate synovial sacs that do
Christoph Lischer not communicate in healthy horses. Distension of the
graduated from medial compartment can be palpated cranial to the medial c
the University of f
collateral ligament. e
Zurich in 1989. He
is currently chair The femoropatellar joint has a large suprapatellar
of equine surgery d
at Glasgow and is pouch and lateral and medial recesses. It communicates
based in the Weipers with the medial femorotibial joint in the majority of T
Centre for Equine
Welfare. He is a
horses and the lateral compartment in a small percent-
diplomate of the age of horses. Distension of this large joint is most pro-
European College of Cranial aspect of the left stifle showing the bones
nounced proximal to the tibial tuberosity, between the
Veterinary Surgery (ivory), menisci (blue) and ligaments (white). A Patella,
and has a special middle and the medial patellar ligaments. B Medial trochlea of the femur, T Tibial tuberosity,
interest in fracture The menisci are crescent-shaped fibrocartilaginous a Medial collateral ligament, b Lateral collateral ligament,
repair in horses. c Medial patellar ligament, d Middle patellar ligament,
structures that lie between the respective femoral and e Lateral patellar ligament, f Origin of long digital extensor
tibial condyles to form congruent articulations. muscle

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2 3

Medial (left) and lateral (right) aspects of the left stifle showing the bones and the three joint
compartments. 1 Medial femorotibial joint, 2 Femoropatellar joint, 3 Lateral femorotibial joint.
Illustrations, Mathias Haab


The collateral ligaments stabilise the femorotibial joint
in a mediolateral direction and are palpable through the
MEDIAL COLLATERAL LIGAMENT originates on the e c
medial femoral epicondyle and inserts on the tibia dis-
tal to the medial condyle. It often has an insertion at the f
medial meniscus;
LATERAL COLLATERAL LIGAMENT originates on the i x b

lateral femoral epicondyle and inserts distally on g

the palpable head of the fibula.
The cruciate ligaments stabilise the joint in a cranio- h k
caudal direction:
femur on the lateral part of the intercondylar notch
and inserts on the tibia cranial to the intercondylar
CAUDAL CRUCIATE LIGAMENT originates on the femur Proximal aspect of a left tibia showing the ligaments
and menisci. a Lateral collateral ligament, b Medial
in the cranial aspect of the intercondylar notch and collateral ligament, c Medial patellar ligament, d Middle
inserts in the popliteal notch of the caudal tibia. patellar ligament, e Lateral patellar ligament, f Long digital
extensor muscle, g Medial meniscus, h Lateral meniscus,
The short meniscal ligaments hold the menisci in place i Cranial cruciate ligament, k Caudal cruciate ligament,
by attaching them cranially and caudally to the tibia. x Intercondylar eminence. Illustration, Mathias Haab


Extra-articular muscletendon units include the quad- sion leads to hock extension via the superficial digital
riceps and the patellar ligaments (responsible for exten- flexor tendon, while stifle flexion leads to hock flexion
sion) and the biceps femoris and the gastrocnemius through the tendinous fibularis tertius muscle.
muscles (chiefly responsible for flexion). The gliding
motion of the patella across the femur allows smooth
extension of the stifle and increases the mechanical APPROACH TO ACUTE STIFLE INJURIES
advantage of the quadriceps. The patella is positioned by
the medial and lateral femoropatellar ligaments and, more PHYSICAL EXAMINATION
importantly from a clinical point of view, by the medial, In the authors opinion, it is not possible to attribute a
middle and lateral patellar ligaments, which extend from particular hindlimb gait to stifle lameness. For this rea-
the distal aspect of the patella to the tibial tuberosity. son, a thorough examination of the entire lame limb is
The large medial trochlea and the medial and middle essential to rule out any other sources of pain.
patellar ligaments are modifications to the equine stifle Acute lameness associated with the stifle may mani-
that are a major component of the passive stay appara- fest as marked diffuse swelling, which often compli-
tus, which allows the horse to stand with minimal mus- cates an accurate anatomical diagnosis. More localised
cular exertion. The movement of the stifle and hindlimb swelling is usually associated with distension of syno-
is also affected by the reciprocal apparatus: stifle exten- vial structures. Distension of the femoropatellar joint can

In Practice SEPTEMBER 2008 427

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be seen if the area around the affected stifle has been

The position of skin wounds can lead to suspicion of
synovial penetration. However, it is important to remem-
ber that the skin over the stifle moves a long way during
stifle flexion and extension, so wounds that appear dis-
tant from the synovial structures of the stifle while the
horse is standing may still communicate with them.

It is sometimes possible to identify pain associated with
specific palpable structures. For example, tibial crest frac-
ture palpation can sometimes elicit a painful response.
However, diffuse swelling and pain mean that it is not
always possible to identify injured structures immediately.
Wounds to the stifle should be thoroughly investi-
gated, using sterile gloves, in an attempt to determine
Horse with diffuse swelling their exact position and extent and identify all the
of the stifle. The bruising of anatomical structures involved.
the skin in the area of the
tibial tuberosity was only
observed when the stifle Cranial (left) and lateral (right) views of a left stifle MANIPULATION
was clipped with marked effusion of the femoropatellar joint
The reciprocal apparatus means that flexion of the stifle
leads to flexion of the tarsus, so full limb flexion is not
be obvious and is sometimes evident when the horse is specific for stifle lameness. More specific stifle manipu-
viewed from the side. Bruising from external trauma is lative tests have been described, including the patellar
common in horses that collide with fences but might only displacement test, the cruciate test and the collateral lig-
ament test but, in the authors opinion, they provide little
reliable additional information. Acutely lame horses will
often strongly resent the tests and guard the limb, thus
Palpable structures and approaches for preventing them from being carried out.
needle placement for analgesia
Diagnostic analgesia is performed during lameness
A investigation when there are no signs localising the
lameness to the stifle region. Response to local analge-
sia is variable and depends on the specific condition. In
acute stifle injuries with localising signs, intra-articular
analgesia is not routinely performed. However, it might
c d e be useful in facilitating special radiographic projections
for which potentially painful stifle flexion is required.
The preferred approaches for needle placement in the
e B
2 three joint compartments of the stifle are shown in the
3 box on the left. They are used during lameness investi-
2 gation, as well as to rule out joint sepsis. As communi-
a 1
b D cation between the compartments is variable, injection
of all three compartments is recommended. Alternative
1 approaches are described elsewhere (Bassage and Ross
T 2003).

Lateral (left) and medial (right) views of the stifle indicating the palpable structures (see Radiography
table below) and the recommended approaches for needle placement in the three joint Stifle injuries with severe lameness should be radio-
compartments. 1 Approach to the lateral femorotibial joint just proximal to the tibial
plateau between the long digital extensor tendon and the lateral patellar ligament. graphed as soon as possible. Standard radiographic
Horizontal needle placement is in a slightly caudomedial direction. 2 Approach to the projections of the stifle are lateromedial, flexed latero-
femoropatellar joint between the medial and middle patellar ligaments in a proximal
direction. 3 Approach to the medial femorotibial joint approximately 2 cm proximal medial, caudocranial and caudal 30 lateral-cranio-
to the tibial plateau between the medial patellar ligament and the medial collateral medial oblique. A cranioproximal-craniodistal oblique
ligament. Horizontal needle placement is in a slightly craniomedial direction
view (skyline) can be used to highlight the patella.
Radiography can demonstrate bone changes such as
fractures and bony remodelling, as well as highlighting
Bones Outline of the patella (A)
Lateral epicondyle of the femur (B Origin of lateral collateral ligament)
the position and extent of soft tissue injuries.
Lateral (C) and medial (D) tibial condyles
Head of the fibula (F Insertion of lateral collateral ligament) Ultrasonography
Tibial tuberosity (T)
In acute cases with suspected synovial sepsis, ultrasonog-
Soft tissue Medial (a) and lateral (b) collateral ligaments
Medial (c), middle (d) and lateral (e) patellar ligaments
raphy is very useful for differentiating between joint
Long digital extensor tendon (f) capsule distension and generalised soft tissue swelling.
This technique is currently the only non-invasive imag-

428 In Practice SEPTEMBER 2008

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Skyline views of a normal patella (above) and a patella

with a fracture line (below) at the medial aspect (arrow).
Pictures, Donnington Grove Veterinary Surgery

Positioning of the hindlimb to obtain a skyline view of the

patella. To avoid the abdominal wall, the x-ray beam
is angled in a dorsolateral-ventromedial oblique direction.
Adduction of the distal limb may facilitate positioning
further by enabling the stifle to be rotated outwards

ing tool available to assess soft tissue structures in the

stifle, including the collateral and patellar ligaments and
meniscal damage (Dik 1995, Hoegaerts and Saunders
2004). It may also be helpful in the examination of
superficial bone injuries such as tibial crest fractures and
subchondral bone cysts on the medial femoral condyle.

Nuclear scintigraphy
Nuclear scintigraphy is not particularly sensitive or spe-
cific and, because stifle lameness is often caused by soft
tissue damage, cannot be relied on to rule out stifle lame-
ness. However, this modality can be useful for detecting
fissures or fractures and avulsion injuries to the stifle.

Arthroscopy has become an essential tool in the diag-
nosis and treatment of femoropatellar and femorotibial
joint disease (McIlwraith and others 2005). Soft tissue
Scintigraphic images of the lateral view of the left
injuries such as cruciate ligament damage, meniscal (above left) and right (above right) stifle three
tears and cartilage lesions that may be inapparent using days after a tibial crest fracture. Intense, increased
radiopharmaceutical uptake can be seen in the
other imaging modalities can be investigated arthro- proximocranial aspect of the right tibia.
scopically. Indications for arthroscopy in acute cases Caudolateral-craniomedial views of the same
fracture (arrows) four (below left) and 10 (below
include the removal of bony fragments and the investiga- right) days after the injury. Note the widened
tion and flushing of wounds that penetrate the synovial fracture gap on day 10, resulting from bone
structures. This technique often enables a more accurate resorption in the early phase of fracture healing

prognosis for horses suffering from stifle injuries.



The three areas most susceptible to fractures are the tibial
crest, the trochlear ridge of the femur, and the patella.

Fractures of the tibial crest

Horses with fractures of the tibial crest are usually
acutely and severely lame following direct trauma. Local
swelling, skin bruising and a painful response to direct

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Unstable, displaced and articular fractures require

internal fixation if the fragment is large enough. A nar-
row dynamic compression plate contoured to the cranial
aspect of the tibial crest with sufficient screws distal to
the fracture line is the treatment of choice to stabilise
these fractures and to counteract the distraction forces of
the quadriceps muscle. Small fragments can be removed
if this does not result in disruption of the middle patellar

Conservative treatment of non-displaced, small frag-
ments has a good prognosis for a return to competition.
Similarly good results are reported for fractures managed
with adequate internal fixation. The majority of horses
are able to return to work after three to six months.
Displaced intra-articular fracture
(above) repaired with a narrow dynamic
compression plate (right) Fractures of the trochlear ridge of the femur
palpation are variably present. Crepitus and instability Acute moderate to severe lameness and a marked disten-
of the tibial crest may be appreciated in displaced and sion of the femoropatellar joint are the typical clinical
unstable fractures. signs of fractures of the trochlear ridge of the femur.
Stifle flexion results in a painful response and crepitus
DIAGNOSIS may be felt during manipulation.
Fractures of the tibial crest vary in shape and size and
may involve the femorotibial joint. Bone fragments DIAGNOSIS
may be prone to displacement by the pull of the patellar Straight lateromedial and flexed lateromedial (if the
ligaments. Several radiographic views are often required horse allows) are the best radiographic projections
to identify the fractures and to define their configura- to visualise fragments from the trochlear ridge. The
tion. The caudolateral-craniomedial view is usually the fracture site might not be obvious if the fragments are
most useful projection due to the unique shape of floating freely in the joint.
the tibial tuberosity. Scintigraphy might be helpful in
some cases. TREATMENT
Surgical removal of free-floating fragments from the joint
TREATMENT is recommended to minimise the risk of osteoarthritis
Most fractures of the tibial crest heal satisfactorily with developing. This is not an emergency procedure unless
rest alone. In the presence of an open wound, adequate there is a perforating skin wound and joint penetration is
wound management and broad-spectrum antimicrobials suspected. A few days of box rest with anti-inflammatory
should be instituted. It is important to monitor the heal- drugs is usually advised to reduce soft tissue swelling and
ing process by taking serial radiographs. Horses should intra-articular haemorrhage before surgery.
be cross-tied or put in a sling for the first two weeks
to prevent them lying down. This is because non-dis- PROGNOSIS
placed fragments can become displaced by muscle pull These fractures usually occur at the lower part of the
as the animal gets up. Daily walking exercise should be trochlear ridge, which is not subject to pressure from the
introduced once stable fibrous union has been achieved patella. Joint function is therefore not compromised and
(usually by 12 weeks after injury) to promote bony union the prognosis is good.
of the fracture.
Fractures of the patella
Patella fractures result in variable lameness, soft tissue
swelling and joint effusion.

Palpation is important to determine whether the fascia
over the patella is intact. If the fascia is intact, a fracture
gap will not be palpable and internal fixation is unlikely
to be needed. Standard radiographs of the stifle may be
inadequate to detect a fracture of the medial aspect of the
patella. The cranioproximal-craniodistal oblique (skyline)
view is crucial in animals with suspected patella fractures.

Lateromedial radiograph
of the stifle showing Small non-articular avulsion fractures generally require
free-floating fragments no treatment other than rest. Once the horse becomes
(arrows) from the distal part
of the lateral trochlear ridge sound, it is generally safe to resume work, although the
of the femur fragment may still be apparent on radiographs.

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Articular fracture fragments from the patella should

be removed because they inevitably lead to osteoarthri-
tis if left in situ. Small fractures can be removed arthro-
scopically, which has the additional value of allowing
femoropatellar joint inspection.
Sagittal fractures and complete horizontal fractures
should be treated with internal fixation.

Surgical removal of the fracture fragments in the
absence of major cartilage damage results in a favour-
able prognosis for a return to full function. Associated
muscle damage, joint capsule tearing or tearing of the
ligamentous attachments to the patella provide a more
guarded prognosis.
Mid-body and sagittal fractures carry a fair to good
prognosis if rapid, accurate anatomical repositioning is
achieved at surgery.


The most important question relating to stifle wounds
Pre- (left) and postoperative (right) flexed lateromedial radiographs of the stifle of a horse
is whether penetration of the synovial structures has showing intra-articular fragments from the patella that were removed arthroscopically
occurred. Signs, diagnosis and treatment are markedly
different for wounds that penetrate the stifle joint
compartments and those that do not. this allows assessment of the soft tissue structures of the
stifle and removal of bone fragments or foreign material
Wounds penetrating the synovial structures from the joints. Intra-articular and systemic antimicrobials
CLINICAL SIGNS are also indicated.
Horses with wounds penetrating the synovial structures
usually present with acute severe lameness unless the PROGNOSIS
joint capsule is open allowing drainage. If treated promptly, the prognosis is good, but it is poor for
chronic infection.
Investigation of the wound using sterile gloves can reveal Wounds that do not penetrate
exposed joint structures or the presence of synovial fluid. the synovial structures
If it is possible to access the joint through healthy tis- CLINICAL SIGNS
sue, the integrity of the affected joint should be assessed Moderate to marked lameness that reduces in severity
using arthrocentesis and a pressure test. Arthrocentesis is the usual clinical sign in horses with stifle wounds
through infected tissue carries a very high risk of joint that do not penetrate the synovial structures. Horses with
contamination and should be avoided. cellulitis or abscesses show more severe, prolonged lame-
ness and can end up with massive swelling in the region.
Prompt, aggressive lavage of the synovial structures DIAGNOSIS
involved, preferably using arthroscopy, is recommended as Clinical examination and thorough wound investi-
gation is required to confirm the structures involved.
Ultrasonography is useful to rule out joint involvement.

Appropriate wound management with adequate drainage
is essential. Cellulitic limbs benefit from systemic anti-
microbials, cold hosing, walking exercise and systemic
anti-inflammatory drugs.

The prognosis is excellent, depending on the soft tissue
structures involved.

Haematomas in the stifle region

Haematomas in the stifle region are formed as a result of
blunt trauma with no skin penetration.

Horses with haematomas present with variable lameness,
which normally decreases in severity within 24 hours
Penetrating injury to the stifle, which communicated with
the lateral femorotibial joint. Synovial fluid can be seen
of injury. Marked swelling can be appreciated, which is
draining from the wound painful on palpation.

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Arthroscopic image of a cranial cruciate ligament (L)

showing tearing of the insertion cranial to the medial
Ultrasonographic image of the lateral femorotibial joint intercondylar eminence of the tibia (I). C Medial femoral
(using a lateral approach) of a horse presented three days condyle
after a traumatic injury to the stifle. The lateral meniscus
(LM) is slightly displaced, the lateral femorotibial joint
is distended (*) and there is a significant amount of nosis for return to athletic use because of joint instabil-
subcutaneous soft tissue swelling (**). LFC Lateral femoral
condyle, LTC Lateral tibial condyle, POP Origin of the ity and concurrent lesions of the associated menisci and
popliteal tendon, LCL Lateral collateral ligament cruciate ligaments.

DIAGNOSIS Cruciate ligament injuries

It is important to differentiate between haematomas and Cruciate ligaments may also be torn or ruptured. Rupture
joint effusions, using ultrasonography and aspiration of occurs most frequently in the mid-body, although
fluid under strict aseptic conditions. avulsion injuries can occur. Cranial cruciate ligament
injuries are more common than caudal ligament injuries.
Initial treatment includes box rest, cold hosing and admin- CLINICAL SIGNS
istration of anti-inflammatory drugs. If the haematoma is Horses present with acute moderate to severe lameness,
large, open drainage might be required once haemorrhag- which is normally positive to stifle flexion. Femorotibial
ing has stopped (usually four to seven days after injury). joint distension is occasionally present. Crepitus can
occur in severe injuries.
The prognosis for haematomas in the stifle region is DIAGNOSIS
excellent. Horses normally respond well to medial and lateral femoro-
tibial joint anaesthesia. Although no radiographic abnor-
Collateral ligament injuries malities are seen in approximately 50 per cent of cases,
Collateral ligaments can be partially or completely rup- the following signs have been associated with cruciate
tured. Damage to the medial ligament is more common ligament injuries:
than damage to the lateral ligament. Fracture of the intercondylar eminence of the tibia;
New bone cranial to the intercondylar eminence;
CLINICAL SIGNS Fragmentation of the femoral attachment of the
Ligament ruptures cause severe lameness, stifle instabil- cruciate ligaments.
ity and pain on palpation. Sprains result in moderate to As the position of the ligaments makes accurate
severe lameness, often with thickening of the ligament. ultrasonographic imaging very difficult, arthroscopy is
Flexion of the limb is usually painful. the only technique available to confirm the diagnosis.

The response to intra-articular analgesia is variable. Strict box rest and NSAID treatment followed by a con-
Stressed caudocranial radiographic views may show trolled return to exercise is recommended. Intra-articular
widening of the joint space. Ultrasonography is helpful anti-inflammatory drugs can also be used.
to image the ligaments for signs of disruption.
TREATMENT Moderate to severe injuries carry a poor prognosis for
Management involves administration of non-steroidal a return to function. However, horses with mild injuries
anti-inflammatory drugs (NSAIDs) and six weeks box have a fair prognosis for a return to athletic function.
rest, followed by a controlled return to exercise. Healing
should be monitored using ultrasonography. Meniscal and meniscal ligament injuries
Medial meniscal injuries are more common than lateral
PROGNOSIS injuries and are often associated with damage to the cra-
Simple sprains carry a fair prognosis for a return to nial meniscotibial ligament. These injuries are frequently
moderate use, but complete ruptures carry a grave prog- associated with other soft tissue injuries of the stifle.

432 In Practice SEPTEMBER 2008

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Stifle injuries are an important cause of lameness in

the hindlimb of horses. The stifle is a complex joint
and therefore a good understanding of its anatomy and
function is essential when dealing with acute injuries.
Most of the traumatic injuries to the stifle resulting in
fractures or joint sepsis carry a good prognosis if treated
promptly and aggressively. Acute injuries to some of the
important soft tissue structures of the stifle can be hard
to diagnose and carry a more guarded long-term progno-
T sis, even with appropriate, rapid treatment. Arthroscopy
has become a very important technique for diagno-
L sis and treatment of injuries to the femoropatellar and
femorotibial joints.

The authors would like to thank Urs Muller, Vetsuisse Faculty, University of Zurich,
Arthroscopic image of (above) a grossly normal cranial for preparing the bone model of the equine stifle used in the figures on pages 266
ligament of the lateral meniscus (L) and (below) one with a and 268, and Mathias Haab, also at the Vetsuisse Faculty, for the illustrations on
tear. Note the cartilage damage (arrows) in the condyle of page 267.
the femur (C). T Tibial condyle
BASSAGE, L. H. & ROSS, M. W. (2003) Diagnostic analgesia. In Lameness in
the Horse. Eds M. W. Ross and S. J. Dyson. St Louis, Saunders. pp 119-120
C DIK, K. J. (1995) Ultrasonography of the equine stifle. Equine Veterinary Education
7, 154-159
HOEGAERTS, M. & SAUNDERS, J. H. (2004) How to perform a standardized
ultrasonographic examination of the equine stifle. In Proceedings of the Annual
Convention of the American Association of Equine Practice. Denver, USA, December
4 to 7. pp 212-218
McILWRAITH, C. W., NIXON, A. J., WRIGHT, I. M. & BOENING, K. J. (Eds) (2005)
Diagnostic and surgical arthroscopy of the femoropatellar and the femorotibial
joints. In Diagnostic and Surgical Arthroscopy in the Horse, 2nd edn. London and
Philadelphia, Mosby Elsevier. pp 197-268

Horses have moderate to severe lameness. Femorotibial
joint distension and/or crepitus are variably present.

Horses usually respond well to medial and lateral
femorotibial joint analgesia. In acute cases, no radio-
graphic signs are expected. New bone on the cranial
aspect of the medial intercondylar eminence, dystrophic
mineralisation and osteoarthritic changes are sometimes
observed in chronic cases.
It is possible to identify some of the more severe,
superficial injuries of the menisci ultrasonographically
in the region of the collateral ligaments. The cranial
and caudal poles of the menisci and the short ligaments
are best investigated arthroscopically. The severity
of tears has been graded to allow more accurate

Treatment involves three weeks strict box rest and
the administration of NSAIDs. Intra-articular anti-
inflammatory drugs can also be used. A controlled
return to exercise is advised, with no free exercise for
six months.

Mild injuries carry a fair prognosis for a return to ath-
letic function, whereas moderate to severe injuries carry
a poor prognosis.

In Practice SEPTEMBER 2008 433

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Diagnosis and management of acute stifle

injury in adult horses

Richard Reardon and Christoph Lischer

In Practice 2008 30: 426-433

doi: 10.1136/inpract.30.8.426

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