Corticosteroid Joint Injections: An Issue at the Heart of Horse Racing’s Drug Debate: The Guardian 4/28/16

By: Daniel Ross

With the Kentucky Derby just around the corner, horse racing is once again poised to receive the glare of the public spotlight for the all-too-brief five-week window afforded by the Triple Crown (unless, of course, lightning dares to strike in consecutive years, and a Triple Crown winner manages to capture the public’s imagination long enough for his jockey to secure a spot on Dancing With the Stars later in the fall).

Beneath this spotlight, however, the drug problems facing this embattled industry will also come into stark relief – in particular, one issue that has courted an increasing amount of attention in recent years: the use and, more importantly, misuse of corticosteroid joint injections in racehorses.

Cast your mind back to the 2012 Belmont Stakes, when trainer Doug O’Neill’s I’ll Have Another – the Kentucky Derby and Preakness winner on the brink of possible Triple Crown glory – was withdrawn on the eve of the race through injury. The following month, the New York Times released some of the horse’s veterinary records, with particular attention paid to how the colt had been injected with “synthetic joint fluid” two days before the Belmont.

Then there are the findings from a report into the deaths of 21 horses fatally injured while racing at Aqueduct Race Track in New York between November 2011 and March 2012.

“Many of the horses in this investigation were understood to have had pre-existing musculoskeletal conditions prior to the race in which they were fatally injured,” the report found. “The Task Force believes that the use of systemic or intra-articular corticosteroids may have impaired veterinarians and trainers in accurately assessing horses’ soundness leading up to a race.”

As an example of just how vulnerable joints are to injury – a risk heightened under the added duress of race conditions – a recent review of the New York State Gaming Commission and Cornell University postmortem examinations over the last three years reveals how 45% of horses that died while racing suffered fatal injuries of the fetlock (ankle) joint.

Corticosteroid joint injections are perfectly legal in racing, yet in recent years, a good number of states have scrambled to tighten regulations surrounding their usage. So, why are corticosteroid joint injections given in the first place? And exactly why are they such a bone of contention in the sport?

“They can make a huge difference to a horse with soundness issues,” said trainer Jim Cassidy, president of California Thoroughbred Trainers and a veteran in the industry. “It’s no different to a human getting his knee or ankle or elbow injected. If everything were done in moderation, everything would be great.

“Unfortunately, that’s not been the case,” he added. “Some of these guys think that if a little bit’s good, a lot’s got to be better. But it’s not.”

Why are corticosteroids used in horse racing?

As they are with humans, anti-inflammatory corticosteroids are widely used on horses to treat swelling and pain associated with joint disease and arthritis. They’re typically used in combination with a synthetic hyaluronic acid, which replicates the synovial fluid already in the joint capsule. And if you ask Jeff Blea, a veterinarian based at Santa Anita racecourse, joint injections can be a real benefit to horses suffering from the usual aches and pains associated with the rigors of a training schedule.

“It can help restore the natural state in the joint,” he said. “And literature has shown that, in some circumstances, it can actually be protective of a joint.” The trick is, Blea said, to use corticosteroids selectively, and almost always as a last resort in tackling joint issues.

He will rarely inject a high-motion joint – typically the knee, ankle and stifle joints – without first x-raying it in order to determine whether more severe underlying problems such as bone chips or fractures are causing the horse’s soreness or lameness. “That’s just good ethical and moral practice.”

Perhaps most crucially, Blea will ordinarily inject a single joint only once or twice over a relatively short space of time. If a horse needs more than two injections into the same joint, “you’re probably missing something larger,” he said.

The problem is, not all racetrack veterinarians are as conservative in their use of joint injections as Blea is.

Too frequently, corticosteroids are used repeatedly on a single joint within a relatively short timeframe, said Dr Dionne Benson, executive director of the Racing Medication and Testing Consortium (RMTC), an umbrella organization attempting to bring drug uniformity to the nation’s racetracks.

“Just like any medication, if misused, they can cause damage,” she said.

Then there are those who use corticosteroid joint injections as a matter of routine before a race, irrespective of whether it “coincides with a medical diagnosis” or not, she said. “We’ve seen what is called six-packs and 12-packs being used, where people injected six joints or 12 joints all at once … That goes against sound medical practice.”

The problem with injecting a joint within days of a race, said Benson, is that the pain-numbing effects of the corticosteroid could mask the symptoms of a potentially more severe problem.

“If you’re doing an injection a couple of days before a race, that horse may just jog or walk

[before it runs], which doesn’t give the horse a chance to show us whether there’s a more serious issue that could surface when they’re racing at top speed in company,” she said.

To get an idea of how much pressure is exerted on a horse’s joints, modeling studies have found that approximately 4,500lbs of force is exerted through the knee just at a trot (though no such studies have been performed on horses galloping at race-speeds of around 40mph).

So, just how ubiquitously are corticosteroids used in the sport? One of the most glaring examples of corticosteroid abuse that Dr Rick Arthur has seen during his time as equine medical director for the California Horse Racing Board concerns a horse that fatally fractured an ankle mid-race.

“That horse’s ankle had been injected 14 times in the previous 18 months,” Arthur said, “including eight times in its previous six starts.”

Nevertheless, some experts on the issue are apprehensive about drawing direct links between catastrophic breakdowns at the joint and use of corticosteroid joint injections.

Evolving science

Dr Wayne McIlwraith’s eureka moment came in 1983.

He was performing surgery to remove bone chips from a horse’s joint, and had expected to find all of the usual problems in the joint, like wear and tear of the cartilage. Only, the joint was surprisingly clean. And given how corticosteroids were widely believed to accelerate joint degeneration, McIlwraith commented to the horse’s veterinarian how the joint had obviously never been injected.

“The vet replied, ‘Oh, I’ve injected that joint 20 times,’” said McIlwraith. “And a couple of revelations came from that, one being that certain corticosteroids don’t cause the damage that others do, or are purported to.”

Now director of Orthopedic Research at Colorado State University, McIlwraith’s decades of studies have brought him to conclude that two of the three most commonly used corticosteroids in racing don’t necessarily damage joint cartilage, and one can actually help protect the joint from arthritis and other degenerative diseases.

The other commonly used corticosteroid – methylprednisolone acetate – can damage joint cartilage, however. And though the use of methylprednisolone acetate in racing has decreased, “there is still more use of the drug than I would like,” McIlwraith said. “It is the least expensive and the longest acting, but if you’re looking at the long-term health of the joint, it’s not appropriate.”

Still, though his research has proven that corticosteroids can indeed protect joints from damage through disease and wear and tear, McIlwraith said that it doesn’t mean they should be used indiscriminately. “And there’s certainly no need or justification for injecting within three or four days of a race,” he added.

Tightened regulations

The RMTC first introduced its own set of corticosteroid thresholds back in 2012. Recommended withdrawal periods range between one week to 21 days before a race, depending on the particular corticosteroid as well as dosage. And so far, 22 states have adopted the RMTC’s corticosteroid thresholds, with another eight either considering them or in the process of adopting them.

Three states have yet to adopt the RMTC’s corticosteroid standards, and therefore may not be regulating corticosteroid usage.

But have these regulations proven successful in curbing the use of corticosteroids in racing as a whole? Statistical data is relatively limited, said Dr Dionne Benson, but anecdotal evidence is “definitely very positive.”

“Before these regulations were enacted, whenever I was on the back-side of a racetrack, I wouldn’t see many horses jog for the veterinarian,” said Benson. “Since this time, on more than one occasion, I’ve actually seen trainers line up their entire string of horses and have a veterinarian watch them jog. To me, that’s a great change.”

New York – which alongside adopting the RMTC’s standards has implemented an online veterinary database for trainers and vets to record and share things like corticosteroid joint injections – reports that there has been a virtual elimination of methylprednisolone acetate treatments. While the number of thoroughbred racing fatalities in New York has dropped nearly 50% over the past five years.

California adopted the RMTC’s standards in October 2014, before which, there were no corticosteroid thresholds in the state, said Dr. Rick Arthur. Since then, the new regulations have had a “dramatic effect” at reducing their use, he said, pointing to figures that support his claim.

During the regulation’s 90-day implementation period, for example, approximately 10 percent of the tests returned positive. But in the past nine months, there have been four corticosteroid violations from 11,726 individual tests, he said.

While the regulations have effectively stopped corticosteroids from being used within days of a race, however, Arthur admitted that they haven’t necessarily stopped the repeated injection of corticosteroids into the same joint.

“That would be one thing the regulations wouldn’t do,” he said. “If you inject one joint every six weeks, you wouldn’t necessarily test over the limit.”

Amid the ongoing debate surrounding corticosteroid usage, some trainers advocate for a more traditional and holistic approach to treating ailments and injuries.

While there’s nothing wrong with joint injections, “if you do it right,” said Jack Van Berg, former winning-most trainer in the US who conditioned Alysheba to victory in two legs of the 1987 Triple Crown, “it’s when they’re giving it in six–packs, two days before a race, that’s a disgrace to racing,” he added.

Ultimately though, time off, rest and recuperation are remedies more powerful and effective in the long-term than any joint injection, Van Berg added: “My dad always said: ‘If you don’t give them time, they’ll make you take it.’”