In Wake of Mongolian Groom Fatality, Both High- and Low-Tech Diagnostics Can Spur Improvement

Veterinarians who work in the Thoroughbred industry are still a year or two away from being able to make better practical use of emerging digital imaging technologies to avoid racehorse injuries before they happen, but there are some low-technology tools and practices that can be implemented to identify at-risk horses at both high-profile racing events and on a day-to-day basis.

That was the takeaway message in a half-hour Thursday teleconference that featured Dr. Larry Bramlage. The internationally recognized equine orthopedic surgeon was fielding media questions one day after the release of a highly anticipated post-mortem report that Breeders' Cup Ltd. commissioned him to write.

Bramlage wrote in his 25-page analysis that while there was no veterinary “cover-up” in the fatal injury suffered by Mongolian Groom (Hightail) in the 2019 GI Classic, teams of veterinarians did miss opportunities to scratch the gelding before his left hind leg fractured catastrophically at Santa Anita Park Nov. 2 in the highest-profile championship race (TDN's full coverage of that report is here).

Yet Bramlage underscored this caveat several times during the teleconference: Even if vets have the world's greatest diagnostic technologies at their disposal, horses are always going to have aches, pains, and routine stiffness that a skilled vet is going to have to identify and assess first before deciding whether or not the issue warrants closer scrutiny via imaging.

And even then, Bramlage said, there are real-world complications that can limit theoretical diagnostic capabilities.

“I don't think you'll ever be able to image every horse that's entered,” Bramlage said. “It's just not practical. The right way to do it is to trust the regulatory veterinarian to pick out the horse who meets the threshold” of showing signs of needing more detailed imaging.

“These are high-level athletes, and every high-level athlete [has] a certain degree of stiffness, and needs to warm up before any race,” Bramlage explained. “The difficult question is 'Is this just routine soreness?'… There's a certain degree of stiffness that's expected.

“All horses have always gotten wear and tear as the result of the process of training,” Bramlage continued. “I don't think horses are that much different than they've ever been. Our awareness is way more attuned to what's going on with the horse, and in fact, we're actually much better at picking out injuries well before they become as severe as the ones that we're talking about today.”

In his report, Bramlage wrote that digital radiographs, nuclear scintigraphs (bone scans), computerized axial tomography (CAT scans), standing magnetic resonance imaging (MRI), and positron emission tomography (PET scans) are among the imaging tools that are “promising but…still not perfected.”

On Thursday, Bramlage expanded upon the evolution of veterinary imaging.

“I think the three-dimensional imaging of CAT scans will eventually become an imaging method that we will use because it's quick, it has a bit higher accuracy than radiographs,” Bramlage said. “Radiographs have made tremendous progress in the digital age, but we still are [looking at] a two-dimensional image.

“The PET scan is an added resource in that you can use the PET scan to get the physiology of the injury that you [first] pick up with the anatomy of CAT scan, or vice versa,” Bramlage said.

“But those technologies are just coming of age and they're not quite mature yet. I think in a year or two we will be using one or both of those as a method to look at the horses that we think need to be [given extra scrutiny] in some fashion,” Bramlage said.

Four horses at the 2019 Breeders' Cup were identified as stiff or choppy enough in their week-of-race examinations that the veterinary team did escalate the level of scrutiny to radiographs, Bramlage said.

But Mongolian Groom was not one of them. Bramlage wrote in his report that post-mortem radiographs showed the gelding had small, pre-existing stress fractures in both hind cannon bones, but because he did not show any asymmetrical lameness, the team of vets did not flag him for any imaging before his fatal race to have a closer look.

“Mongolian Groom, he was so similar to how he had been over the last six months of racing that he didn't stick out as having anything particularly different going on,” Bramlage said. “So it's potentially possible, had he been radiographed, [that] you might have found something. But you might have found nothing.”

The quarter-inch cannon bone lesion that Bramlage subsequently saw on an enlarged radiograph when compiling his report is the type of lesion a vet would look for, he said, “but you have to have exactly the right radiographic view to find it.”

Bramlage outlined six suggestions in his report that he said could improve exam processes moving forward. When asked on Thursday which of those ideas might be most beneficial, he did not hesitate to highlight a potential low-tech solution: The availability of a space on the backstretch that is essentially a 60-foot-radius circle where vets can observe horses at a routine jog while controlled by a handler.

Jogging horses in a straight line—the standard pre-race exam practice—has its limitations, Bramlage said, because a horse can seem to have a choppy gait that disappears when it is allowed to move more rapidly. If a horse still looks “off” when jogging circularly, a vet could escalate the diagnostics to the imaging level.

Creating jogging circles seems like a low-cost tool to implement, but Bramlage gave a few reasons as to why they haven't yet been added to most racetrack backstretches.

“Space is usually limited. It does take time—it adds time to the exam,” Bramlage said, even after estimating that a regulatory vet might only call for three or four such circular jogs a day. “And it's not all that useful in the whole spectrum. It's only really useful if you have a horse that you don't actually like the way he's moving, and then it helps you in determining whether that's just [stiffness] or whether there actually is a significant lameness in some fashion.”

Plus, the horse has to cooperate. “Jogging in a circle doesn't always agree with the horse,” Bramlage said. “They'll try to rear, and the way we handle that if we're doing a routine lameness exam is to tranquilize them. And it makes them settle down [to] show us where their problem is. But you can't do that before a race, because the tranquilizer would show up in a post-race test.”

Bramlage repeatedly shifted back to the point that regulatory vets always will be the first line of defense in the pre-race soundness exam process.

“The evolution of the regulatory veterinarian is relatively recent, and it's the single biggest factor in [reducing] injury rates over time,” Bramlage said. “I think the racetracks are coming on board with looking at their own injury rates and employing [veterinary] professionals who are good at [spotting problems before they progress]. That didn't happen a few years ago.

Regulatory vets “do a good job,” Bramlage said. “They want to do a better job. We give them a little bit more [in terms of tools] to work with, we should continue to move forward.”