Hock Joint Injections: Why the difference in prices?

By Dr. Jay Joyce of Total Equine Veterinary Associates

Owning a horse is rewarding yet can be expensive, and finding value in every aspect of ownership is important.  However, value in veterinary services is much more difficult to ascertain than simply comparing 24-oz bottles of fly spray.  This is likely because there are no veterinary treatment standards, and every horse’s needs are different.  To demonstrate this point, we are going to focus on “hock injections” as owners tend to shop-around for a “good price” believing that all injections are the same. 

COMMENTARY:  Value is sacrificed by “cheaper injections” - don’t be fooled.  Cheaper usually means less effective medications and fewer joints treated.  This will only harm your horse and your pocketbook in the long run.

You may not realize that each hock has 4 individual joints (8 joints for both legs).  Each joint can have degenerative, arthritic changes regardless of the horse’s age and previous work history.  The most commonly injected hock joints are the lower, or distal, 2 hock joints; but often there is some arthritis in all 4 of the joints.  Therefore, there are potentially 8 joints to inject (4 per leg).  Joints anatomically communicate when they share joint fluid; the lower two joints rarely communicate, which is why vets inject the lower two joints individually.  However the upper two joints almost always communicate, thus we can treat the upper two joints as one, combined joint.  This means we should inject the lower two joints individually and one “combined” injection for upper joints; thus effectively treating all 4 joints with only 3 needle injections per hock.  You should expect to see your vet injecting each leg 3 times. 

QUESTION: How many of your horse’s hock joints does your veterinarian inject?

COMMENTARY:  Based on clinical examination and diagnostics like digital radiology, we routinely administer 6 joint injections to medicate all 8 joints, unlike some “less expensive” veterinarians who typically inject only 1-2 joints per leg.  Since we have most of the hock area sterilized and prepared for injection, it is not difficult to add an additional joint to the treatment.  We do not charge for the additional injections, only for the increased amount of medications.  We consider this the more correct approach in most cases, and a value-added service for our Blue Ridge clients. 

Too often, veterinarians don’t recognize this, or they simply don’t want to appear more expensive.  Some veterinarians may elect only to inject the most distal joint…thereby only injecting 1 of 3 (or 2 of the 6 total) necessary joints.  Their cost to you will be less because only a portion (1/3) of the job was done.  This is horribly misleading to owners.  The horse will improve because “a little of something is still better than nothing” (the medication will diffuse slightly around the injection site seemingly having a bigger affect) and owners are satisfied because their horse’s hocks were injected for a perceived lower cost.

COMMENTARY: The lowest hock joint is a relatively easy joint to access for your veterinarian from the lateral, or outside, of the leg.  The next joint higher is much more difficult to access and some veterinarians shy away from administering medication in it.  This joint requires the veterinarian to inject from underneath the horse on the opposite side to reach the medial, or inside, of the leg.  It is harder to access and requires more proficiency.  Some vets skip it.  Just because it is difficult to accomplish doesn’t justify not doing it.

Joint injections likely cost more because more joints are actually treated.  We have discussed the number of physical joints treated and why veterinarians vary in their methods. But that’s only half of the story.  There are two fundamental reasons that make “hock joint” joint injections expensive.  One is the number of joints injected and the other depends on the type of medication administered. 

There are great, very effective medications, and there are less good medications.  Then there exists various combinations of medications used.  Generally, the better the medication; the greater the cost.  So a “cheap” joint injection may contain either no hyaluronic acid (HA) or it may contain a HA that is vastly inferior and poorly effective.  No HA, or use of a poorly effective HA, keeps the overall cost of the “hock injections” less expensive.   

QUESTION: What HA does your veterinarian use, and why?   Again, the horse will improve because “a little of something is still better than nothing.”

COMMENTARY:  Based on current veterinary research, we choose only to provide the highest quality of products.  We use only FDA-approved HA labeled for joint use in the horse.  We do not use illegal, generic, or compounded substances in horse joints. 

And yes, veterinarians can choose to use inferior products and products not specifically designed for use in the horse’s joint.  Drug use is a poorly regulated aspect of veterinary medicine.  Maintaining the highest standards in our profession depends upon individual veterinarians’ integrity, knowledge, and motivation to provide quality services. 

So why should you care if your horse gets only 1/3 of its hock joints injected or receives a cheaper, inferior product?  Inferior or inadequate products need more frequent administration because they are less effective and this leads to increased risk of negative outcomes like infection, joint flare, and diminished response to the injections.  Would you really choose injections twice as often with inferior products?  Has your veterinarian explained this?  How much better could your horse feel and perform if treated properly?

COMMENTARY:  How much money are you really saving if you must have your “hock injections” done twice as often?  Or how much better would your horse perform if treated properly?  Again, who willingly chooses to do work twice as often at half-effectiveness?  You would not choose these options if you were given the time and consideration by your veterinarian to make educated decisions.

Now to complicate things ever further, it may become more common place to use glucosamine (like Adequan) as part of the joint therapy.  Adequan has been shown to help repair and restore the cartilage surface.  This is incredible news for the horse, and it may become the dominant product used in the joint in conjunction with steroids, HA, and antibiotics.  Scientific studies may soon demonstrate Adequan’s effectiveness in the joint.  Absolutely, this will help the horse.  But the downside will be increased owner cost.  The already expensive “hock joint” injections will become more expensive.  But if Adequan proves to heal the joint, then maybe the injections could be done less frequently.  In an economy where owners are shopping for the least expensive therapy (although inferior) and resisting new, improved therapies, additions like Adequan will be difficult to introduce.

“Hock joint injections” involve medicating the appropriate joints with appropriate medications like high quality HA, steroids, possibly antibiotics, and potentially Adequan. 

Don’t just ask your veterinarian to “inject hocks” or “how much does it cost?”.  Ask your veterinarian, “Which of the 4 hock joints are being injected, and why?” and “What medications will be used, and why?”  If after working with your veterinarian, you don’t understand the answer, or are uncomfortable with their answer, then switch veterinarians.  You wouldn’t go to the same restaurant twice if they had poor service and bad food.  You need to absolutely understand what is happening to your horse, and you should understand the reason behind the cost of care.  In almost all examples, you will find cheaper joint injections are due to inferior products and/or lack of injecting all the hock joints. 

Your horse’s medical care is not like shopping for fly spray.  Not all care is equal.  Choose your veterinarian because they provide high quality services and respect you enough to fully explain the procedures being done on your horse.  Don’t choose your veterinarian because you’re shopping for a good price.  You are smarter than that, and your horse deserves better.   

Commentary:  So simply asking your friend what they paid for “hock injections” or calling around to various vet practices is entirely misleading.  To make an educated comparison, you need to know how many joints are being treated, and exactly which medications will be utilized.  The least expensive prices will coincide with fewer joints treated and the use of inferior, not FDA-approved, off-label, or illegal products.  You should neither be jealous of a friend with “cheaper” hock injections nor feel that your vet took financial advantage of you.  Actually, you should feel sorry for your friend’s horse that received less quality care, and you should thank your vet for treating your horse like a VIP!

Owners strive to treat their horses very well.  The time, energy, and expense of ownership are sometimes overwhelming.  For all that you do for your horse, don’t cut corners on joint care…it’s healthy joints that keep them performing.

A similar case can be made for equine dentistry.  In most cases, supporters of twice a year dentals are performing sub-standard work, likely on un-sedated horses and likely by non-veterinarian lay floaters.  But this is separate issue with several similarities like “a little something is better than nothing”.  More to follow ……..

Dr. Joyce is an equine practitioner working at Blue Ridge Veterinary Associates in Purcellville, VA.  He is a graduate of the United States Naval Academy in Annapolis, MD. , and he earned his veterinary degree with Honors from the University of California, Davis.  He has special interests in lameness, dentistry, and Wellness Programs. He recently lectured at the World Equine Veterinarian Conference in Brazil.

Get on the “Contact List” at Blue Ridge Vets so you can join Dr. Joyce for either one of several annual Equine Seminar Socials at local vineyards, or at a local farm for “Ask the Vet” Day.  Everyone is welcome.