Equine Tendon And Ligament Injury Recovery Checklist

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Medrego - 2019 Facts:

Every third sport horse has a tendon, ligament, joint or cartilage injury during its career.

70% of injured horses are unable to reach their previous results.

Repeated injuries occur in 66% of all cases. After injury has healed - scar tissue forms and horse can remain lame.

No matter what sort of treatment you choose when your horse injures a tendon or a ligament, the most important treatment will be time. Tendons and ligaments go through a much slower process of healing than other body tissues because of the way they are built. Both structures consist of an organized network of dense and elastic connective tissue. It is rich in protein called collagen. Fibers of collagen stretch to take the load when your horse puts his weight on the leg and spring back when the weight comes off. If the load that your horse puts on his leg is too much, the fbers can tear. The torn fbers repair slowly because the amount of cells that help tendon and ligament tissue regenerate are relatively low. In addition to this - tendon and ligament tends to have a poor blood supply.

To get the best result after recovery you will need to follow a carefully crafted rehabilitation program. Consult your veterinarian in order to provide the best care for your horse. To help you navigate in this complicated and time consuming challenge, we have created a 12 step recommendation programm. Remember that each horse is different and so are the injuries. We have provided general guidelines that can be adjusted by your horses specifc needs.

How to Properly Manage Recovery

1. Cool Down

Why cooling down is needed?

The frst stage of healing is “infammatory stage”r which generally takes place frst fve or seven days after the injury.This is a usual response of the body to an injury. Redness and heat are caused by increased blood fow. As the result of increased fuid movement and white blood cell movement swelling occurs. If infammation process is prolonged there is a risk of it leading to atrophy of muscles and decreased ability to activate the muscles, resulting in a secondary tissue damage. Ice cooling your horses injury can also help limit the blood vessel fuid leakage into the surrounding tissues thus preventing infammatory processes. This means that there will be less infammation to start with and your horses healing time will be shortened.

How to apply?

To decrease infammation you should cool down the injured area. It is important to apply cold therapy in the frst two or three days after the injury when the acute stage is in place.

Apply cold therapy carefully as 20 or 30 minutes at once is enough to have the benefcial effects. If you keep applying cold for too long - cold can start to damage tissues. For maximum effect you can do 20 minutes on and 30 minutes off regime for cold therapy.

Cold-water hosing is the simplest way to draw heat out of the injury. Ice water bucket is great if your horse will stand in it. In case your horse won’t withstand the ice cold water bucket, there are many cooling systems available on the market such as Ice Horse that continuously keep the cold circulating around the leg.

You can use crushed ice (in ice boots, for example) as well, but it may be less effective because the surface contact between the ice and the leg is often inconsistent.

Additionally ice treatment will help your horse to feel better almost immediately because of the numbing effects that cold have on tissues.

2. Wrap

Why wrapping is needed?

Applying support for the injured leg is equally as important as cold therapy. Wrapping a leg injury will give support, promote circulation and help reduce swelling which is one of the most important factors in the healing process. By putting on a pressure wrap, the pressure is applied not only for the skin but also to deeper tissues. This will help to even out the pressure throughout the leg therefore reducing swelling. By applying a standing wrap you will also ensure the necessary support for the leg.

How to apply?

It is best to apply a standing wrap. A standard standing wrap consists of a nylon bandage and cotton quilted pad. The injured leg should be dry before applying a standing wrap (a leg quilt secured with a track bandage).

To help stimulate the blood fow you can add liniment directly to your horse’s leg under the wrap before applying a standing wrap. Apply it to your horse’s lower leg and massage it in from the knee down to the ankle to get the blood fowing. Rub until the leg feels dry.

Continue by applying standing wrap. Place the long edge of the wrap against the inner part of the leg so that the top edge would be up to the knee and the bottom edge below the fetlock. Wrap counterclockwise. Always start from the inside and go forward unrolling the wrap by applying gentle and even pressure. Place the bandage on the inner part of your horse’s leg against the wrap facing away from the leg. Start from the middle of wrap and unroll the bandage counterclockwise and downward with even pressure. Once you reach the bottom, start wrapping upwards. Carefully line up the hook-and-loop attachment of the bandage.

Additionally you can use a mild poultice with the bandage to help draw out heat, but avoid any agent that could irritate the skin or increase infammation.

Bandage the opposing leg as well, for support in case the horse shifts load from the injured leg. Reset bandages at least once a day. Standing wrap shouldn’t be too loose or too tight. Seal the top and the bottom of the wrap to ensure that debris won’t get near the wound.

3. Medicate

Consult your veterinarian to understand the size and location of the injury. It is necessary to perform ultrasound to assess the proper healing regime. Your veterinarian may prescribe medication, usually phenylbutazone (bute), funixin meglumine (Banamine) or a similar nonsteroidal anti-infammatory drug during this period.

Besides reducing infammation, these drugs help make your horse feel more comfortable. But keep in mind that these medications won’t help improving the healed tissue quality.

Alternative therapies to improve healing results

Nowadays there are available cutting edge cell based therapies that can actually improve the quality of the healed injury. Any repair process usually produces scar tissue over a large period of time. This newly formed scar tissue is very different from what a normal tendon or ligament structure is like. When the highly organized tendon fber structure is disrupted by injury, it will never be the same. It also means that the amount of mechanical stress that a horse can endure is less and that there is a larger possibility for the same injury to reoccur.

Stem cell therapy is one of the most effective regenerative medicine treatments available. It is a fast growing feld both in veterinary medicine and human medicine. This treatment allows us to use body’s own repair tactics to achieve a better healing result. Stem cells are used to make up different necessary body tissues such as muscle, bone, blood and nerves.

In order to avoid any scar tissue, 2 weeks after the acute infammation process has decreased, apply stem cell therapy to the affected area. This will help to create new cartilage, fat and fbrous tissues. Injected stem cells will be drawn to the affected area and recruit cells from other areas of the body to promote tissue regeneration. Stem cells allow better repair with formation of more organized tissue and less scar tissue. In this way your horse will be able to return to full amount of function with a signifcantly smaller chances of recurring injuries. A large advantage to stem cell therapy is a faster regeneration which means faster recovery time. Your horse can be up and in 3 to 6 months instead of the usual 9 to 12 month recovery period.

It is best to apply stem cell therapy up to a month after the injury. If the healing process has advanced already before stem cell therapy application, the effects of therapy might not be as effective.

Platelet-Rich Plasma or PRP therapy is another commonly used regenerative medicine. It has a rich concentration on platelets - small cell fragments that are present in blood. Usually they are helping blood to clot but it can also release high concentration of growth factors that promote healing. When injecting PRP to the affected area, it releases powerful healing proteins that stimulate tissue repair. This can be used separately or together with stem cell therapy for best results.

4. Confne

In most cases, strict stall rest is best at frst. Since confned horses tend to display undesirable behaviours you should care for your horses wellbeing also while he is confned. Ensuring that the stall have a good ventilation is important for airway health and for keeping your horse well rested and healthy. Any excess dust particles in the stall can have a negative effect on your horses wellbeing. To prevent this you can use high quality hay/bedding, clean stalls from any used (urine soaked) bedding or hay twice a day. If you have any fans installed in the stall, try to place them so they don’t whip up any dust particles.

Always consult your veterinarian to understand the best approach for rehabilitation of the injury. If the healing process is going as planned, you can start working out the plan of exercise for your horse. If his injury is mild and he's not lame, you may start brief - sessions as described in the next section.

5. Early Recovery - Begin Controlled Exercise

Lightly loading the injured tendon stimulates collagen formation, and it encourages collagen fbers to align in a way that maximizes strength and fexibility. In order to adjust your horses recovery accordingly to the individual healing process, it is best if you repeat ultrasound scans to determine how healing process is going.

Remember that doing too much too soon risks reinjury. With your veterinarian's OK, begin short periods of controlled exercise just hand-walking. Experts from University of California at Davis have developed the best rehabilitation protocols of exercise based on studies involving 2800 horses. To understand how much walking is best for recovery look at the table below.*

INJURY 0 - 30 days 30 - 60 days 60 - 90 days

Hand walk 15 min Hand walk 40 min Ride at walk 20 - 30 Mild twice daily daily min daily

Hand walk 15 min Hand walk 40 min Hand walk 60 min Moderate twice daily daily daily

Hand walk 15 min Hand walk 30 min Hand walk 40 min Severe twice daily daily daily *Carol L.Gillis. 1997. Rehabilitation of Tendon and Ligament Injuries Vol. 43: 306 - 309.

In addition to ensure the best results you can use aquatic therapy like underwater treadmill or swimming pool for rehabilitation and conditioning of injury. It has the ability to improve healing without overstressing a particular injury. Consult your veterinarian to provide the best rehabilitation plan for your horse.

There are additional ways to improve injury healing process. Shock wave therapy has been available for those who want to help the horse to heal faster. It promotes healing of wounds by increasing growth factors, reducing infammation and stimulating tissue proliferation and it will provide a signifcant pain relief. Shock wave therapy stimulates cell activity thus creating a stronger outer layers of bones and cell networks underlying joint cartilage.

6. If needed - medicate again There is always a risk of reinjury. While walking and exercising with your horse, keep in mind that the movements should be controlled. If there is a behavior problem, talk to your vet about sedative medications to control your horse while exercising. This will decrease chances of reinjury and help the recovery process by continuing to slowly mobilise injured parts. Sedatives will reduce excitement and irritability in case your horse will get too excited about the exercises after being kept in stall for some time.

Generally, horses should be off anti-infammatory meds after cool-down period. When there is no more heat associated with the injury, fbroblasts get busy producing new collagen to repair the damage. Prolonged interaction with NSAIDs (Nonsteroidal anti- infammatory drugs) can have long-term side effects, and there's evidence that they slow healing process.

7. Let Your Horse Rest In Stall

For the best recovery results keep your horse in stall during the main healing time which will be recommended by your vet based on healing progress. Even in the smallest paddocks there is possibility of your horse engaging in the wrong movement and decreasing the wound healing time by tearing some of the healed tissue or even worse - injure themselves again.

It is best if you continue using the standing wraps for three to six weeks, depending on how severe the injury is. After that you can gradually decrease the time spent in wraps in order for your horse to regain complete control over the injured area.

8. Walking Under Tack

After six weeks, depending on the progress of the healing and severity of injury have your vet check your horse's progress. If the ultrasound shows that healing continues to progress and your vet says that the clinical signs are good, it may be time to start easy walking with the rider on. With your vet's approval, you may be able to replace some of your daily hand- walking sessions with walking under tack (riding on the horse). In some cases this is safer and more controlled way to remobilise your horse. Adding riders weight will increase the amount of energy and movement range your horse uses while exercising. This will help the new tissue to form in such a way that builds more resistance and fexibility.

When your horse is ready to start working under saddle, your veterinarian will prescribe the length and number of times this should be done. Be sure your horse's feet are properly trimmed and shod and continue to work on level, smooth footing, walking in straight lines and large circles. 9. Add

How trotting helps regeneration process?

Trotting will help your horse to move with more energy and thus relieving his mind and muscles from the previous restrictions of stall. Trotting is also important for the correct formation of scar tissue. If you help your horse to mobilise in the correct way, the scar tissue will form in line with the healthy tissue rather than creating a rigid scar tissue. Carrying the weight of a rider and swinging his back in long loose strides will work all the muscles of the horse much better that just walking.

How and when to start trotting?

After the 6th week examination by your vet, you might add just fve to ten minutes of trot to your exercise sessions if your vet approves. Usually trotting can begin after you have worked your way up to 25 to 30 minutes tack walking. To make sure the tendon is warmed up, perform trot in the middle of walking exercise. Do not, however, trot deep into corners or on tight circles yet, and still refrain from asking for lateral work.

10. Ultrasound Needed Again

If your horse continues to trot sound on circles and straight lines, and his leg shows no sign of heat or swelling, you may be able to gradually increase his work. Before engaging your horse in more activity - get new scans with your vet. Your horse might just be able to begin again. Keep in mind that quite frequently horses suffer from repeated injury because of resuming athletic activity too soon. You can never be too careful when it comes to checking with your vet to see the progress of rehabilitation.

11. Higher Activity

When your horse is well along in his exercise program, your vet may tell you it's OK to put him out in a small paddock. He should go out solo, at a quiet time when other horses won't be acting up in order to avoid unnecessary stress. In addition to this you can start cantering and slowly increasing the length of each canter until your horse in confdent enough to return to full work. Starting with trotting into small grids with the jumps spaced appropriately for the horse’s stride will have the best results.

appropriately for the horse’s stride will have the best results. Any horse is likely to behave in an unpredictable manner when frst out after months in a stall. It is better to talk to your vet if you will need medications to keep him calm at least for a frst few days.

12. Preventing recurring injury

While it is impossible to completely avoid injury in horse you can take some proactive steps to minimise the risk of injury occurring again.

 Provide good footing for the areas where your horse performs. Maintain the area even and adjust the depth of footing accordingly to the activities that your horse usually engage in. For a dressage or jumper horse 1 to 2 inches (3 to 5 cm) of footing is enough, but for cutting horse it is best to provide 6 to 8 inches (15 to 20 cm) of coverage.

 Correct shoeing is critical to minimize the stress induced to soft-tissue structures. Keep the hooves balanced so that your horse can work with minimal resistance from ground. Trim your horse so that the hoof angle would mirror the angle of the coffn bone inside the hoof for best results. This angle is different for each horse. To fnd the perfect angle take --rays to learn your angle.

 Condition your horse adequately for the intended exercise. Long and slow walks that take about 40 minutes are best to strengthen soft tissue structure.

 Warm up before exercise is always crucial. Before riding your horse, give him a chance to warm up properly for at least 10 to 15 minutes.

 Learn to recognize any signs of pain or injury before it becomes severe. Carefully examine your horse each day before you start to work. Pay attention to behaviour changes or changes.

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