Various Treatments
Tendon and ligaments heal at a fixed rate. Assuming optimal circumstances 6 months is a general figure with another 6 months to a year to allow for maturity and strength.
Many different treatments are recommended! Any time there are multiple treatments for a single problem we have to realize that no one has the definitive answer and what works for one horse or injury may not work for another. When choosing a treatment one must consider the logic behind it, the cost involved and most important the ability to follow through on a controlled rehabilitation program.
The trick to any tendon injury is getting it to heal with minimal scar tissue formation and with as much realignment of tendon fibers as possible. Scar tissue is not elastic, so any scarring (thickening) of the tendon is detrimental to its elasticity. For this reason it is logical for horses that bow to have a surgical release on the superior check ligament. This procedure compensates for a certain amount of residual scarring by indirectly lengthening the tendon (see superficial flexor tendon injuries). Elasticity of the structure is promoted by initial therapy and rest. This is followed by a rehabilitation program that includes stall rest simultaneously with a controlled exercise program that is monitored by ultrasound examinations.
Initial therapy should always include icing and anti-inflammatory medication. This should continue until there is minimal heat left in the limb since inflammation persists in tendon lesions causing them to increase in size if left untreated.
Tendon Splitting
Most tendon or ligament tears are within the tendon structure (core lesions) where they can neither drain or receive a good blood supply. Surgical tendon splitting has been used successfully for decompression and as a means to allow for revascularization of the deeper areas of the tendon or ligament. The problem with tendon splitting is that a certain amount of healthy tissue is damaged by nature of the surgery and healing is therefore affected.
Tendon Injections
We are now injecting PRP (Platelet Rich Plasma) and Stem Cells acquired from Bone marrow. this is commonly combined with Shockwave therapy.
Stem Cell and PRP Injection
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At present this is our treatment of choice for high suspensory and other ligament or tendon tears. The bone marrow is taken from the chest and processed in a specialized centrifuge to concentrate stem cells and PRP. PRP has growth factors and combined with stem cells can form tissue duplicating the original. This technique is especially useful for more difficult cases such as injuries at ligament -bone junctions (high suspensories). Some cases may not warrant the expense of stem cells and PRP can be acquired simply by taking a syringe full of the horses blood and processing it at our clinic in our "Magellan" system.
Shock Wave Therapy
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We were initially quite sceptical about this technology but it has proven to be the most effective noninvasive approach to tendon/ligament healing that we have come across! Data to its efficacy in healing tendons was presented at the AAEP and the annual surgery conference and we continue to use shock wave therapy on more and more horses.
Controlled Rehabilitation Program (CRP)
We have had the opportunity to work with hundreds of tendon and ligament injuries. Many horses have returned to peak performance levels but we have had our share of failures as well. In retrospect most of the failures were because of inappropriate activity and inadequate monitoring during rehabilitation. As a result we have developed a very strict controlled rehab program (patent pending) which is initiated soon after injury. Other important issues to address during and after rehab are foot care, footing, and adequate fitness. Nutrition is an important consideration. One must ensure that the feed is cut back so the horse doesn't jump out of his stall or get laminitis. At the same time sufficient protein must be maintained to provide for proper healing. Nutriceuticals such as Equine Power, collagen and oral glycosaminologycans seem to be beneficial in the healing process but controlled studies on tendon/ligament healing are lacking.
Superficial Flexor Tendon Injuries
Even with optimum healing there is less elasticity in an injured superficial flexor (SFT) resulting in a higher chance of re-injury. Dr. Larry Bramlage's technique of cutting the superior check ligament under general anesthetic allows an extra centimetre or so of give that compensates for the loss of elasticity. Statistics have shown that a thoroughbred racehorse treated conservatively for an SFT injury still has an 80 % chance of re-injury within the first three races after recovery. Cutting the check ligament reduces the re-injury rate to 20 %. Horses that need to pursue athletic careers will greatly benefit from this surgery.
This surgery is routinely done using a minimally invasive approach (tenoscopically) at Kleider Vet Services. Our experience and those of others does not show that on operated horses there is any greater increase in suspensory injuries than in the normal racing population. This was previously a concern which had to be addressed since a paper that published this comment did not take into account the suspensory injuries in the non treated population.
K.V.S Rehab Programs General Comments
Stall Rest
This faze of rest is important to ensure the initial healing response. Stall rest must be continued during the total controlled rehab program as well. Well over a decade ago, I attended the Dubai International Equine Symposium on tendon and ligament injuries where an 80% re injury rate was quoted for a horse that was turned out – i.e. an uncontrolled rehab program. Walking in conjunction with stall rest is allowed until trot work is initiated (according to Dr. Kleider’s recommendations based on ultrasound findings).
How much walking? Start at 5 minutes and working up to 20 minutes a day prior to starting trot work.
Frequency? Walking can be done two to three times a days if so desired.
Do I have to walk my horse? If he walks a lot in the stall and is likely to hurt himself/handler being hand walked or ridden then common senses should prevail – leave him in a stall. A larger stall is a favorite alternative.
Hot walkers, walkers, treadmills etc? Great labor saving devices. The former machines are on a circle which may only revolve in one direction. If they go to the left and the horse is sore when he stretches his right front then this could exacerbate his lameness. Footing and safety need to be considered.
“I can’t stall rest my horse! He’ll go crazy!!” Our recommendations for this problem are as follows:
- Provide a friend either beside or across from your horse. Horses are social animals and hate being left alone. If a horse is not possible then a goat or other animal may be a source of amusement.
- Entertainment devices such as Jolly Balls, Lick its, music, and believe it or not even videos of horses frolicking can be a source of entertainment.
- Sedation: Short acting and long acting tranquilisers on an as need basis.
- A stall sized paddock outside can be made by making the existing paddock smaller.
The Walk
Intended for stretching and is especially important for tendon and ligament injuries. Horses rarely re injure themselves at this gait unless they get away from the handler or rider, so judicial use of sedatives and proper use of restraint is advisable when rehabbing horses at this gait. In riding horses flat work training at the walk is useful to keep their mind occupied and prevent them from “exploding”. For example shoulder in, leg yield, half pass, renvers, travers, and rein back can all be done to promote healing as long as the transition into each exercise is fluent and not abrupt.
The Trot
Most of the strengthening work is done at this gait because:
- the load is shared with the diagonal hind or fore limb
- It is not as fast as the canter and therefore it is safer (the horse is not as prone to re injury).
The Canter
Canter is done at the end of the program. At the canter weight bearing occurs on each leg individually so there is maximum load on the bones, joints, tendons, and ligaments. Remember “Speed Kills” so initially keep the pace slow at least until the end of the program. Introduce sharp turns late in the since any imbalance may cause re injury.
Footing
Generally hard footing is better for tendon and ligament injuries, while soft footing is better for bone issues. Irregardless the consistency is more important thane the type. A horse stepping from a hard surface into a soft “hole” is much more prone to re injury. If you have a tendon or ligament injury and you only have soft footing to work in than you can make things easier for the horse by
A. Going the opposite way of the lameness for example: if a horse is off in the right front longing to the left then do most or all of your work initially to the right for the first few months or until the tendon/ligament injury is healed. This strengthens the limb without over stretching.
B. Doing more straight lines and fewer circles, stay away from tight circles until the end of the program and then introduce them gradually.
What About Time off??
Unless it’s greater than two weeks rehab programs may be continued where they left off.
Click on a link below to select a PDF document outlining our rehab programs:
