The Bare Bones: a Primer with Dr. Bramlage

He hasn't got all day; nor, doubtless, do you. So let's cut to the chase. We won't dwell on the journey that has made Dr. Larry Bramlage a doyen of orthopedic science, in its daily application to the racehorse: not the alphabet soup of honors and distinctions, nor the long experience that has honed the sharpest diagnostic eye in the business through 23 years with Rood and Riddle. We have simply dropped into the clinic, on a recent visit to Lexington, to direct a brief sunbeam of his knowledge and insight into the practices of those who depend for a living on the miraculous but fragile equilibrium of the bones that support a Thoroughbred.

“Racehorses are so good because they produce their skeleton based upon what they do,” Bramlage begins. “They're not born with it. Their skeleton is the minimum weight that they can produce and still carry them around the racetrack. So they have a big engine, but their undercarriage is no heavier than it needs to be. And that's why they're fast.”

That's true, in some evolutionary measure, of all horses–and other animals, too, people included.

“The skeleton is different than hearts and lungs and muscles,” Bramlage explains. “Those train to a volume of work that you're doing. Skeleton trains to the level of work that you do.”

He recalls a series of experiments conducted on turkeys some years ago, where one wing was restricted and the fowls learned to flap the other to get food. The idea was to establish how many cycles of this activity were required to stimulate bone.

“Well, it's interesting,” Bramlage says. “Because when you reach 36 cycles in a day, that's the maximum the bone will respond to. You can go to 2,000 and it won't get any stronger than in those 36. And that's what makes a trainer's job tough. Because they have to push the horses hard enough, that they get strong enough to carry themselves around the racetrack. But if you do too much, then those extra cycles begin to be destructive.”

Those 36 cycles, for our purposes, apparently equate to about a furlong. Which, Bramlage explains, means that your fastest eighth will be the level for which your horse produces bone. Obviously that doesn't happen overnight, albeit bone is far more dynamic than most laymen assume.

“But the stimulus is there that it'll try to reach that next level before the exercise does,” Bramlage explains. “And then you repeat that over and over, and eventually the skeleton gets appropriate enough that you don't acquire any damage during those 36 cycles. So while there's some always ongoing wear-and-tear, the most important part of making a racehorse is usually up to four or five races. Once they get there, their skeleton is virtually made.”

The living nature of bone, however, does mean that the “made” skeleton can regress once taken out of training. But Bramlage is keen to address a misapprehension, which took root maybe a decade ago, that persistently galloping a young horse creates the foundation for a strong skeleton.

“Galloping a horse a lot helps the heart and lungs–but once you go past those 36 cycles in a day, the rest of them are just wear-and-tear,” he explains. “A lot of horses were actually harmed by excess galloping.”

Previously there had also been the attempt to extrapolate the principles of interval training, in human athletes. “I knew a couple of people who, as runners themselves, were going to interval train and beat everybody,” he recalls. “And they ended up with 4-year-old maidens with splints on their hind legs. Because the skeleton just can't take that that many fast intervals. In people, the limiting system is the heart and lungs, not the skeleton. Horses have such great heart and lungs that, unless they're bleeders, they virtually never limit. The horse's heart and lungs can respond to anything you throw at them. But the skeleton has to do it in little stair steps. And that's how, in young horses especially, the heart and lungs often get ahead of the skeleton.”

Though the tibia also registers trouble here–it absorbs a lot of force, in locking the reciprocal motion of stifle and hock–the most familiar symptom is shin trouble.

“You go too fast, the wear-and-tear begins to exceed the response and you get bucked shins,” Bramlage continues. “Shins have to triple in size. The front cortex of a cannon bone in a 'made' racehorse is three times thicker than in the yearling that started training.”

So how does this translate, ideally, into building up a young horse towards a race? Bramlage suggests a pretty familiar scenario: one or two furlongs at a rather higher level than the rest of the exercise, in effect showing the skeleton where it's going to be asked to go in three days' time. The real skill, in training, is monitoring attitude.

“People ask, what makes a good trainer?” he says. “For me, it's an easy question. It's being able to understand when the horse is happy and when he's not. When horses are adapting well, they're happy to train. When a horse starts not wanting to go to the track in the morning, not wanting to load in the gate, those are the kind of things you need to look out for. It's a real art for trainers to understand when to push a horse and when to back off.”

Obviously you would hope that trial and error, over the generations, should have brought horsemen's intuitions pretty close to where they might land through learned science.

“If you go back to when Aiken, South Carolina, was the winter training center–because that's how far the railroad went south–they would have the Aiken trials and those 2-year-olds, early on, would be breezing an eighth,” Bramlage says. “Those short breezes were actually very useful to the horses. Especially when you're making the horse, it's a matter of trying to train heart and lungs–because you have to do that–without overtraining the skeleton.”

When a horse is past that stage, but has to be laid off training, the skeleton will not lose much strength through the first month but the situation will change pretty rapidly after two months. And a more significant spell, say four months, notoriously invites humeral or tibial stress fractures in a small number of horses: again, because heart and lungs train back so much faster than the skeleton.

Needless to say, by the time a horse is sent into the clinic, they have typically signaled a loss of form.

“If a horse has swelling in a knee or ankle, those guys at the racetrack pick it up,” Bramlage says. “These horses [sent into the clinic] don't have any obvious pain, heat or swelling, but their form has gone down. And a lot of times they have either bilateral lameness–two fronts or two hinds, sometimes all four–or they're just early wear-and-tear injuries. I think most of the really successful trainers today understand better than they did 10 years ago that the horse is subject to that wear-and-tear; and that whenever a horse is not giving you what it can, then you need to start looking.”

Parallel advances have been made in imaging technology. It is barely 30 years since radiographs were still processed on celluloid. Digital radiographs have themselves improved dramatically, and now scanning in three dimensions via CAT and MRI and ultimately PET is available.

“Nuclear imaging was a huge tool because those scans allowed us to look for stress fractures that didn't have any outward clinical signs,” Bramlage says. “But whenever regulators think in terms of needing a PET scan to monitor horses at the racetrack, that's not really true. You need to look at them and identify the horse that needs to be looked at, not scan them all. Most of those can be unraveled using all the tools we currently have. It's just a matter of knowing when you need to look. And so more than we need more equipment, we just need to look more often.”

The role of regulatory veterinarian is a contentious and evolving one. The process is being aided, however, by a growing injury database to succeed anecdotal assumption. Already Bramlage can see where this might take the profession.

“It may not hit during my lifetime, but I think the next really exciting revolution, which is going to totally change our care of racehorses, is digital timing,” he says. “It just makes sense that it will eventually move away from clockers and all be done passively, automatically, by the equipment. Well, when you have that data, it's not a real hard step to write an algorithm that identifies [problems that may be brewing].

“You could look at a horse's exercise fingerprint because stride length and stride cycle is pretty stable for individual horses. When the length begins to shorten, he's protecting something. And so each horse will have his own digital fingerprint, and this will be automatically recorded every time a horse works, every time they race. And all of a sudden you can say, 'This horse is getting into trouble.'”

Some early research has detected patterns that might anticipate injury as many as three races ahead. Bramlage can see a future where every horse will transmit data to central monitoring for red flags. For now, until the necessary technology is available, it falls to people like Bramlage to determine the level of risk that warrants its prohibitive cost.

“But I think that in the next generation beyond me, that will become automated,” he predicts. “And that will revolutionize the prevention of injuries. It'll be the best thing that ever happened.”

And that's one of the things that maintains such youthful enthusiasm in a septuagenarian who has already witnessed such transformation in the tools of his trade: the curve is only going to steepen.

Aside from digital radiography, the biggest leaps forward have been internal screws and plates; plus arthroscopy and its adaptation from diagnosis to treatment. For internal fixation, the initial debt was apparently to a Swiss cost-benefit analysis of chronic disagreement between tibias and ski-boots. Of arthroscopy, meanwhile, Bramlage muses: “Surgery never used to happen until there wasn't anything else you could do. Then with the arthroscope it became easier, quicker, better. And so now that is the first line of defense. The horse gets a chip fracture, they take it out right away. The joint doesn't degenerate, they go back to normal.”

Horsemen nowadays have gained faith that condylar fractures can be routinely secured. One of Bramlage's most celebrated patients, Personal Ensign, went a long way to changing perceptions. Nowadays you'll find many a Breeders' Cup winner with a screw lurking somewhere in its skeleton. It's a very different world from when Bramlage started out, and yet he feels we have barely started.

“Yeah, we were dipping X-rays in chemical solutions when I was a student,” he reflects. “But the young veterinarians right now will probably see the same explosion. Probably in the biologic areas: the understanding of cell biology, and cell communication, is doing the same ramp up. The ability to treat is going to be much more pointed and effective than now.”

Bramlage is acutely aware of our industry's exposure to an ever more urban society that professes ever fiercer vigilance on behalf of animals with which it typically has little interaction, certainly compared with generations past. In that respect, veterinary regulation manifestly has a front-line role. He's excited, then, that a digital fingerprint might give mute animals a new way of telling doctor what's wrong.

Even with the advent of such tools, however, Bramlage believes that the essential mystique of the Thoroughbred will endure. We might be able to explain how everything fits together, and learn how to put things back together, but the key to performance will remain elusive.

“And actually I hope we never do get to that point where we understand everything about a horse,” he admits. “Because I think that's what's intriguing to people. You can improve your odds by improving your breeding. You can keep the horse healthy, you can have a trainer that's capable to that level. You can do all those things, but you still can't just go buy a Derby winner.

“Every horse is a product of a dip out of the gene pool. It's not a one-to-one combination of the mare and the stallion. There are all sorts of units. Like you've got four genes that cause eye color in people. There are all those different combinations of things. So to combine whatever comes out of that gene pool with the mental capacity, to train hard enough and compete hard enough, you never know which horse is going to have it.”

He chuckles, and asks whether you ever heard of a racing mule named Black Ruby?

“Well, she was on the California fair circuit for about 10 years and there was only one other mule could occasionally beat her,” he explains. “But they cloned her several times, and none of them could beat me. They had the exact same genetic makeup, but none of them would run like that. So that elusive factor, I think, is what keeps people intrigued. And I hope we never identify that.”

Even his exceptionally intimate professional relationship with horses, ranging from Personal Ensign to claimers at Ellis Park, has only marginally clarified the enigma.

“I don't know that there's any one thing,” he says with a shrug. “Good horses are always physically attractive, well balanced. They're almost always smart, they're very intelligent, very adaptable.”

Does that make better horses better patients, too?

“Absolutely,” he replies. “But racehorses are the best patients anyway, in my opinion. The worst patient is the 4H horse that's never felt anything but a rub rag, because when they have to deal with pain, you never know how they're going to handle it. But racehorses are just like people who train hard: you're stiff and sore next day and then it goes away and you feel better than you did before you started. They have better survival instinct.”

And while recruitment to equine practice is becoming harder, given the reduced social exposure nowadays between young people and horses, Bramlage guarantees endless fascination to the next generation. The measure of your work, he says, is so much more gratifying than in small animal practice.

“I think equine practitioners tend to practice a lot longer because there's another level of assessment,” he says. “Your horses have to go back and run. They have to win barrel races. They have to win ribbons, if they're a backyard horse they have to trail-ride. There's a couple of books I read, discussing why do armies fight? It's mostly not for abstract ideals. They fight for the people next to them, the people they trained with, the things they know and the fear of failure. And I think this level of assessment, with the possibility that you'll fail, but the rewards when you succeed, it's higher in horses.”

And there are literally hundreds of horsemen in the Bluegrass who will be relieved to hear him say that. “I could easily be retired,” he says. “At some point, physically it's not going to be possible to continue. But I think that's why people stick around. I mean, when the success barometer is the dog being able to get up on the sofa? That's not quite as intriguing!”