Bucked Shins / Dorsal Metacarpal Disease

Bucked shins, known medically as dorsal metacarpal disease, is a stress-related bone condition affecting the front surface of the cannon bone in young horses, particularly those entering race training. The condition develops when the immature bone of the third metacarpal fails to adapt quickly enough to the high-speed loading demands of training, resulting in microdamage, inflammation, and pain along the dorsal cortex of the cannon bone. This represents one of the most common training-related injuries in young racehorses and has significant implications for training schedules, career development, and long-term soundness. The term bucked shins derives from the characteristic convex swelling that develops over the front of the affected cannon bones as the body responds to bone stress with new bone formation.

The prevalence of bucked shins in young racehorses is remarkably high, with studies suggesting that seventy to ninety percent of young Thoroughbreds in race training experience some degree of dorsal metacarpal disease during their two-year-old training year. Standardbreds also develop this condition, though the pattern may differ somewhat due to their different gait and racing style. The condition almost exclusively affects the forelimbs, which bear approximately sixty percent of the horse's weight and experience the greatest impact forces during high-speed exercise. Most cases occur in horses between eighteen months and three years of age, corresponding to the period when horses are introduced to galloping and speed work while their skeletal system is still maturing.

The impact of bucked shins on the racing industry is substantial, resulting in lost training days, delayed race careers, and financial costs associated with treatment and extended rehabilitation. Horses with acute shin soreness cannot continue training at speed and must be rested until the bone heals and adapts. The timing of bucked shins often coincides with important sale and racing deadlines, creating pressure to return horses to work before complete healing has occurred. Beyond the immediate effects, horses that experience severe or repeated episodes of bucked shins may be at increased risk for stress fractures if training is resumed too quickly or if the underlying bone quality is compromised.

Fortunately, bucked shins is a treatable and often preventable condition when proper attention is paid to training progression and bone health. The body's response to controlled bone stress is to remodel and strengthen the bone, making it more resistant to future injury. The key to successful management lies in balancing the need for bone-strengthening exercise with adequate recovery time between stressful workouts. Most horses with bucked shins make complete recoveries and return to successful racing careers when given appropriate time to heal and when subsequent training is properly managed. Early recognition, prompt treatment, and science-based training modifications have significantly reduced the impact of this condition in well-managed racing operations.

The primary cause of bucked shins is repetitive high-speed loading that exceeds the immature bone's capacity to adapt and remodel safely. When horses gallop or breeze at speed, the cannon bones experience cyclic bending forces as the limb loads and unloads with each stride. The dorsal cortex of the cannon bone is placed under tension during the weight-bearing phase, and repeated tensile loading causes microscopic damage to the bone matrix. In mature bone that has adapted to high-speed work, this microdamage is repaired between workouts through normal bone remodeling. However, in young horses whose bones have not yet adapted to racing speeds, the rate of damage accumulation can exceed the rate of repair, leading to clinical shin soreness.

Bone physiology in young horses explains why this age group is particularly susceptible to bucked shins. Immature bone has a different structure and mechanical properties compared to mature bone, with lower mineral density and organized differently at the microstructural level. The cannon bones of young horses have adapted to the loads experienced during normal growth and development but have not yet remodeled in response to high-speed exercise. This adaptive remodeling is a normal physiological process but takes time to complete. Training programs that introduce speed work too quickly or at too high an intensity do not allow adequate time for bone adaptation, predisposing to microdamage accumulation and clinical disease.

Training factors significantly influence the development of bucked shins and represent modifiable risk factors. Programs that emphasize long, slow distance work without adequate speed exposure may produce horses with bones that are completely unprepared for racing intensity when speed is finally introduced. Conversely, programs that introduce high-speed work too early or too frequently overwhelm the bone's adaptive capacity. The surface on which training occurs matters, with harder surfaces producing greater impact forces and higher risk. Short, intense training periods followed by complete rest may be more damaging than moderate, consistent training that allows gradual bone adaptation. Training in hot weather may alter bone metabolism and healing capacity.

Risk factors for bucked shins extend beyond training to include individual horse characteristics and management practices. Young two-year-olds in their first training preparation are at highest risk due to skeletal immaturity. Large, fast horses may generate greater forces and be at increased risk. Nutritional factors affecting bone quality, including calcium, phosphorus, and vitamin D status, influence susceptibility. Horses returning to training after layoffs may have lost bone conditioning and need gradual reintroduction to speed work. Track conditions, including surface hardness and consistency, affect loading patterns. Racing schedules that demand early performances pressure trainers to advance training faster than bones can adapt.

The pathophysiology of bucked shins involves a cascade of microdamage, inflammation, and attempted repair that underlies the clinical signs observed. Initial microscopic stress fractures develop within the dorsal cortex without causing detectable external changes. As damage accumulates, inflammation develops at the periosteum, the membrane covering the bone surface. This periostitis causes heat, swelling, and pain over the affected area. The body attempts to repair damage and strengthen the bone by laying down new bone over the dorsal cortex, creating the characteristic convex swelling from which the condition derives its name. If training continues at damaging intensity, microdamage may coalesce into larger stress fractures. Proper management allows the repair process to proceed to completion, resulting in stronger, denser bone capable of withstanding racing demands.

Early warning signs of bucked shins may be subtle and require careful observation to detect before obvious lameness develops. Young horses in training may show mild reluctance to extend fully at the gallop or may seem to hold back slightly during fast work. Handlers may notice slight heat or sensitivity when running hands down the front of the cannon bones after training. Very subtle gait abnormalities, detectable only to experienced observers, may appear before lameness is obvious. Changes in behavior after fast work, such as slight reluctance to walk out or standing abnormally, may indicate developing soreness. Trainers and handlers who are attuned to each horse's normal behavior are best positioned to detect these early changes and modify training before the condition progresses.

Common symptoms of established bucked shins are characteristic and typically readily recognized by experienced horsemen. Bilateral forelimb soreness is the rule rather than the exception, as both forelimbs are subject to similar loading during training. Lameness is usually most apparent at the trot and may be subtle or obvious depending on severity. Affected horses often show a shortened, choppy gait in front as they try to minimize impact forces on painful shins. Some horses become noticeably reluctant to gallop or begin to lugging in during fast work. The lameness typically worsens with continued work and improves with rest. Horses may show discomfort when palpated over the cannon bones and may react to even light pressure over the affected areas.

Behavioral changes frequently accompany the physical symptoms of bucked shins. Horses in pain may become irritable during training or resistant to being tacked up. Some horses that were previously enthusiastic about fast work become reluctant or seem to lose their competitive drive. Changes in appetite or attitude in the stall may reflect overall discomfort. Affected horses may stand abnormally, shifting weight off their front feet. Some horses lie down more than usual to relieve pressure on sore limbs. These behavioral indicators, combined with physical signs, help trainers recognize that a horse is experiencing shin soreness and needs modification of its training program.

Physical signs of bucked shins are typically evident on examination of the affected limbs. Heat over the dorsal surface of the cannon bone is an early and sensitive indicator of inflammation. Swelling develops over the front of the cannon bone, initially soft from periosteal inflammation and later firm as new bone forms. The characteristic convex curvature of the dorsal cannon bone surface, from which the term bucked shins derives, becomes apparent in more advanced cases. Pain is elicited on palpation of the dorsal cannon bone surface, with horses often flinching or attempting to pull the leg away. Both forelimbs are typically affected, though one may be worse than the other. Comparison with normal horses or the horse's own previous condition helps identify subtle changes.

Symptom progression in untreated or improperly managed bucked shins follows a predictable pattern of worsening. Mild heat and subtle soreness progress to obvious lameness and significant swelling. The degree of new bone formation increases as the body attempts to reinforce the stressed area. Pain becomes more severe and constant rather than appearing only after fast work. If training continues despite symptoms, stress fractures may develop within the damaged bone, representing a serious progression that significantly extends recovery time. Some horses develop chronic changes that persist even after acute symptoms resolve. Understanding this progression underscores the importance of early recognition and prompt management.

Emergency symptoms requiring immediate veterinary attention include sudden severe lameness, particularly if it follows a specific training event that might indicate a completed stress fracture. Non-weight-bearing lameness on a forelimb during or after training should be treated as a potential fracture until proven otherwise. Significant swelling with severe pain, particularly if localized to a specific area rather than the typical diffuse pattern of shin soreness, warrants immediate evaluation. Any suspicion of a complete or propagating stress fracture requires urgent veterinary assessment, as these injuries may require specific treatment to prevent catastrophic fracture. Radiographs are necessary to differentiate simple bucked shins from more serious bone injury.

Physical examination for bucked shins begins with observation and palpation of the cannon bones. The veterinarian evaluates the horse at rest, noting stance and any visible swelling over the front of the cannon bones. Careful palpation along the dorsal metacarpal surface identifies heat, swelling, and pain response. Comparison of both forelimbs is performed, as bilateral involvement is typical but may be asymmetric in severity. The horse is evaluated in motion at walk and trot to characterize any lameness. Forelimb flexion tests may exacerbate the lameness if significant bone inflammation is present. The examination also evaluates for other causes of forelimb soreness that might be confused with or accompany shin soreness, including foot pain, joint problems, and soft tissue injuries.

Diagnostic imaging provides objective assessment of bone changes and helps differentiate bucked shins from more serious conditions. Radiography is the primary imaging modality, though early bucked shins may show minimal radiographic changes. As the condition progresses, radiographs reveal periosteal new bone formation over the dorsal cannon bone surface, increased dorsal cortical thickness, and potential stress fracture lines. Serial radiographs over time document the progression of healing and bone remodeling. Nuclear scintigraphy, or bone scanning, is highly sensitive for detecting active bone stress and may identify bucked shins before radiographic changes are apparent. Increased radiopharmaceutical uptake along the dorsal cannon bones indicates active bone remodeling and confirms the diagnosis. Advanced imaging such as computed tomography may be utilized when stress fractures are suspected.

Laboratory testing plays a limited role in diagnosing bucked shins but may be useful in certain situations. Serum markers of bone turnover, including osteocalcin and bone-specific alkaline phosphatase, may be elevated in horses with active bone remodeling but are not specific for bucked shins. Blood work may be performed to rule out systemic conditions or metabolic abnormalities that might affect bone health. Evaluation of nutritional status, including vitamin and mineral levels, helps identify any deficiencies that might predispose to bone problems or impair healing. These tests supplement rather than replace clinical and imaging assessment.

Differential diagnosis for forelimb lameness in young racehorses includes various conditions that may present similarly to bucked shins. Stress fractures of the cannon bone represent a more advanced form of bone injury that must be distinguished from simple periostitis. Splint bone fractures or periostitis cause similar forelimb soreness but with pain localized to the splint bone rather than the dorsal cannon bone surface. Suspensory ligament injuries may occur in young horses and cause forelimb lameness with swelling over the cannon bone region. Fetlock problems including joint inflammation or osteochondral fragments can cause forelimb gait abnormalities. Foot pain from various sources remains a common cause of forelimb lameness in horses. Complete diagnostic evaluation ensures accurate diagnosis and appropriate treatment.

Immediate treatment for bucked shins focuses on reducing inflammation and preventing further bone damage through cessation of high-speed training. Rest is the cornerstone of initial management, removing the repetitive loading that caused the condition. Stall rest with hand-walking is typically instituted for acute cases. Non-steroidal anti-inflammatory drugs such as phenylbutazone help reduce pain and inflammation during the acute phase. Cold therapy, including ice or cold water hosing, reduces swelling and provides comfort during the first few days of treatment. The limbs may be bandaged for support and to help control swelling. These initial measures stabilize the condition while allowing the acute inflammatory response to subside.

Medical management of bucked shins centers on controlling inflammation while the bone heals and remodels. Systemic anti-inflammatory medications may be continued for one to two weeks depending on the severity of inflammation. Topical anti-inflammatory preparations applied to the affected area provide local relief. Some practitioners utilize treatments such as shockwave therapy, which may promote bone healing and reduce pain. Bisphosphonate medications, which slow bone resorption, have been used in some cases to help stabilize bone during healing, though their role in managing bucked shins remains somewhat controversial. The mainstay of treatment remains time and reduced exercise intensity to allow natural bone adaptation.

Surgical treatment is rarely indicated for typical bucked shins but may be necessary if complications such as complete stress fractures develop. Horses with confirmed stress fractures may require surgical stabilization with screws or plates to prevent fracture propagation and enable healing. The vast majority of bucked shin cases, however, are managed conservatively with rest and controlled return to training. Surgical intervention is reserved for the small percentage of cases that progress to significant fracture or fail to respond to conservative management. Decisions about surgical treatment require careful imaging assessment and should involve veterinary specialists experienced in equine orthopedics.

Rehabilitation and return to training represent critical phases of bucked shins management. After the acute inflammation subsides, typically two to four weeks, controlled exercise is gradually reintroduced. Initial exercise consists of walking only, progressing to trotting as healing advances. The return to galloping is delayed until the bone has had adequate time to remodel and strengthen, typically eight to twelve weeks or more from the onset of symptoms. The training program should be modified to include shorter, controlled gallops at submaximal speed, allowing continued bone adaptation without overwhelming the healing process. Serial clinical examinations and potentially repeat imaging guide decisions about advancing the training program.

Training modifications to prevent recurrence are essential following recovery from bucked shins. The training program should be restructured to provide gradual, progressive loading that allows bone adaptation. Short, frequent speed works are generally preferable to long, intense workouts for developing bone. Varying the training surface and intensity helps avoid repetitive stress patterns. Monitoring for any return of heat or soreness enables early intervention if problems recur. Many trainers now utilize interval training programs specifically designed to condition bone while minimizing injury risk. The goal is to develop bone that can withstand racing demands through controlled, progressive loading.

Treatment decisions should consider the individual horse's circumstances, including the severity of clinical signs, imaging findings, career timeline, and owner resources. Mild cases caught early may require only brief rest and training modification. Severe cases with significant periosteal new bone formation or stress fracture development require extended rehabilitation. The pressure to return horses to racing should be balanced against the risk of recurrence or progression if training is resumed too quickly. Patience during rehabilitation pays dividends in long-term soundness, as properly healed and adapted bone is less likely to develop problems during subsequent training and racing.

Recovery timelines for bucked shins vary depending on the severity of the condition and the quality of management during the healing period. Mild cases of shin soreness detected early and treated promptly may recover in four to six weeks with appropriate rest and controlled return to training. Moderate cases with significant periosteal reaction typically require eight to twelve weeks before returning to meaningful training. Severe cases with stress fractures or extensive bone involvement may need four to six months or longer for complete healing. The bone remodeling process that ultimately produces stronger, better-adapted bone cannot be rushed, and attempting to shorten recovery often leads to recurrence or progression.

Post-treatment care and monitoring during recovery from bucked shins involves regular assessment of healing and gradual reintroduction of exercise. Clinical examination, including palpation for heat and sensitivity, guides management decisions. Follow-up imaging may be performed to document bone healing and remodeling. The exercise program is advanced progressively, typically starting with walking and adding trotting after two to three weeks of walking only. Galloping is introduced only after trotting is well tolerated and clinical signs have resolved completely. Any return of heat, swelling, or soreness necessitates backing off the exercise program and allowing additional healing time.

Prognosis factors for horses with bucked shins include the severity of initial presentation, the presence or absence of stress fractures, and the appropriateness of subsequent training management. Horses with mild bucked shins that receive appropriate treatment carry an excellent prognosis for full recovery and successful racing careers. More severe cases or those with stress fractures have a more guarded short-term prognosis but may still achieve good outcomes with patience and proper management. Horses that experience repeated episodes of bucked shins may have underlying bone quality issues or training management problems that need to be addressed. The trainer's commitment to appropriate training modification significantly influences long-term outcomes.

Long-term soundness outlook for horses that have recovered from bucked shins is generally favorable when the condition is properly managed. The bone remodeling that occurs during healing actually produces a stronger, more resilient bone capable of withstanding racing demands. Many successful racehorses have experienced bucked shins during their two-year-old year and gone on to long, sound careers. Horses that developed stress fractures may have minor residual bone changes but often remain functionally sound. The key to long-term soundness lies in appropriate training management that continues to respect bone physiology even after recovery. Rushing horses back to intense training before healing is complete increases the risk of recurrence and potential career-limiting injury.

Management practices aimed at preventing bucked shins focus on training approaches that promote gradual bone adaptation without overwhelming immature skeletal tissue. Modern training programs increasingly incorporate scientific understanding of bone physiology to develop conditioning regimens that strengthen bone while minimizing injury risk. Short, controlled speed works at moderate intensity allow bone to experience stress and initiate the adaptive remodeling process without accumulating damaging microdamage. Gradual progression of training intensity over months rather than weeks gives bone time to respond and strengthen. Avoiding long layoffs followed by rapid return to intense training prevents subjecting unconditioned bone to excessive stress.

Nutritional prevention strategies support optimal bone health and healing capacity. Adequate calcium and phosphorus intake in appropriate ratios supports bone mineralization. Vitamin D plays essential roles in calcium metabolism and bone health. Trace minerals including copper, zinc, and manganese contribute to bone matrix formation. Protein intake must be adequate to support bone remodeling and repair processes. Avoiding nutritional imbalances that might impair bone quality is important, and feed analysis and ration balancing help ensure complete nutrition. Young horses in training have different nutritional requirements than mature horses, and feeding programs should be designed accordingly.

Exercise and conditioning approaches that prevent bucked shins are based on the principle of controlled bone loading that stimulates adaptation without causing damage. The concept of preconditioning involves exposing young horses to short, fast exercise before they enter formal race training, allowing bone adaptation to begin before intensive training demands. Interval training programs alternate stress and recovery periods, optimizing the adaptive response. Varying the type and intensity of work prevents repetitive stress patterns. Adequate recovery time between demanding workouts allows bone repair and remodeling between loading sessions. Monitoring horses closely and reducing intensity at the first sign of shin soreness prevents progression to more serious injury.

Environmental factors significantly influence bucked shins risk and should be managed as part of a comprehensive prevention program. Training surface characteristics affect the impact forces transmitted through the forelimbs, with harder surfaces increasing stress on bone. Well-maintained training tracks with appropriate cushioning help protect developing bone. Avoiding training on excessively hard, frozen, or uneven surfaces reduces injury risk. Climate conditions may affect bone metabolism and healing, with some evidence suggesting seasonal variation in bucked shins incidence. The training facility's approach to track maintenance, scheduling, and monitoring contributes to overall injury prevention.

Industry-level prevention efforts have helped reduce the impact of bucked shins over time. Research into bone physiology and training adaptations has informed evidence-based training recommendations. Some jurisdictions have implemented regulations limiting training intensity for young horses. Educational programs for trainers disseminate best practices for developing young racehorses. Pre-training examinations and monitoring programs identify horses at higher risk. Collaboration between veterinarians, trainers, and industry organizations has improved understanding and management of this common condition. Continued research and education remain important for further reducing bucked shins incidence and impact.

Daily management during the acute phase of bucked shins centers on rest and supportive care while inflammation resolves. Stall rest with hand-walking provides controlled exercise without loading stress. Daily observation of the affected legs monitors healing progress, looking for reduction in heat, swelling, and pain response. Bandaging or supportive wraps may be applied if recommended by the veterinarian. Medications are administered as prescribed, typically anti-inflammatory drugs during the initial phase. The stall should have appropriate bedding that provides cushioning without creating too much depth that might stress the limbs. Regular communication with the veterinarian guides management decisions.

Housing and turnout considerations during recovery balance the benefits of rest with the potential negative effects of complete confinement. Small paddock turnout may be introduced as healing progresses, providing more natural movement while limiting the opportunity for explosive exercise that could stress healing bone. Turnout with quiet companions or alone prevents excitement and running. Footing in the turnout area should be level and provide good traction without being excessively hard. The timing and extent of turnout should be discussed with the veterinarian and adjusted based on the horse's behavior and response. Some horses manage well with increased turnout while others require continued restriction.

Exercise modifications during recovery from bucked shins follow a structured progression designed to promote continued bone adaptation without causing re-injury. Walking exercise is the foundation of early rehabilitation, typically beginning during the latter part of the rest period and continuing throughout recovery. Trotting is introduced when walking is well tolerated and clinical signs have resolved. The return to galloping occurs only after extended periods of successful trotting. Speed works are initially short and at submaximal speed, gradually increasing in length and intensity over weeks to months. Throughout this progression, horses are monitored closely for any return of symptoms, which would necessitate backing off the exercise intensity.

Monitoring and ongoing care requirements during recovery include regular veterinary assessments and careful attention to the horse's response to training. Clinical examinations at regular intervals document healing progress and guide advancement of the exercise program. Any heat, swelling, or sensitivity on palpation indicates the need to reduce exercise intensity. Follow-up imaging may be performed at specific intervals to assess bone remodeling. Training records should document exercise intensity, duration, and the horse's response to help identify patterns and optimize the rehabilitation program. Open communication between trainer and veterinarian ensures coordinated management.

Quality of life and use considerations following bucked shins recovery are generally positive, as most horses return to intended uses without long-term limitations. Horses that have recovered from bucked shins can return to racing and often enjoy long, successful careers. The experience may provide an opportunity to optimize training approaches for that individual horse. Some horses may be found to be better suited to different careers if they prove particularly susceptible to bone stress injuries. The emphasis should be on developing each horse to its potential while respecting its physical limitations. With appropriate management, bucked shins need not be a career-defining injury.

High-risk breeds for bucked shins are primarily those used in racing industries where young horses are subjected to high-speed training. Thoroughbreds demonstrate the highest prevalence of bucked shins, reflecting their common use in flat racing beginning at age two when skeletal maturity is incomplete. Studies suggest that up to ninety percent of young Thoroughbreds in training experience some degree of dorsal metacarpal disease. Standardbreds also develop bucked shins at significant rates during harness racing training, though the pattern may differ somewhat due to differences in gait and racing style. Quarter Horses used in racing experience similar bone stress injuries. Arabian racehorses in regions where this breed competes on the flat show comparable susceptibility. Breeds not typically raced at young ages rarely develop bucked shins.

Use and discipline considerations directly determine bucked shins risk, which is primarily a disease of young racehorses. Flat racing at high speed places the greatest stress on the dorsal metacarpal cortex, explaining why Thoroughbreds and Quarter Horse racehorses are most commonly affected. Harness racing subjects horses to somewhat different loading patterns but still produces significant bone stress at racing speeds. Horses in non-racing disciplines rarely develop classic bucked shins because they are typically not subjected to high-speed exercise at young ages. Sport horses introduced to jumping or other demanding work at young ages may develop bone stress injuries, though the pattern differs from racing-related bucked shins. The age at which training begins and the intensity of early training are the primary determinants of risk.

Genetic factors affecting bone quality may influence individual susceptibility to bucked shins, though specific genetic tests are not available. Bone density, cortical thickness, and material properties vary among individuals and likely have heritable components. Selection for early racing performance may inadvertently select against optimal bone development, as horses with less dense, more rapidly maturing bone may race earlier but be more susceptible to injury. Some bloodlines appear to produce more or fewer horses with bone problems, though confounding factors make definitive conclusions difficult. Research continues to explore genetic contributions to bone health in racehorses. Breeding decisions that emphasize soundness along with performance may help reduce bucked shins susceptibility over generations.

Commonly co-occurring conditions with bucked shins include other manifestations of bone stress in young racehorses. Stress fractures of the cannon bone represent progression of the same pathological process that causes bucked shins and may develop if training continues despite shin soreness. Metacarpal stress fractures typically occur in the dorsal cortex and may propagate to complete fractures if not identified and rested. Splint bone fractures or periostitis may develop concurrently with bucked shins. Condylar stress fractures of the distal cannon bone are another manifestation of bone fatigue in young racehorses. Sesamoid bone problems may develop in horses experiencing multiple bone stress injuries. Recognition that these conditions share common origins in skeletal loading and maturation guides comprehensive prevention strategies.

Conditions with similar symptoms that must be differentiated from bucked shins include various causes of forelimb lameness in young horses. Splint bone injuries cause pain and swelling over the cannon bone region but in a different location than dorsal metacarpal disease. Suspensory ligament injuries produce swelling and lameness that may mimic shin soreness. Tendon injuries in the flexor tendon region cause forelimb lameness with palmar rather than dorsal signs. Foot pain from sole bruises, abscesses, or other sources is a common cause of forelimb lameness. Joint problems including osteochondritis dissecans may present with forelimb lameness in young horses. Complete diagnostic evaluation ensures accurate diagnosis and appropriate treatment.

Potential complications of bucked shins include stress fracture development if the condition is not properly managed. Continued training on painful, stressed bone allows microdamage to accumulate and potentially coalesce into significant stress fractures. Complete fractures through stressed bone, while rare, represent catastrophic outcomes that must be prevented through appropriate management. Chronic periosteal changes may persist even after acute symptoms resolve. Horses that experience multiple episodes of bucked shins may develop problematic bone configurations. Compensatory problems in other structures may develop if horses alter their gait due to shin pain. Appropriate management of the initial episode prevents these complications and enables successful long-term outcomes.