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Healing & Rehabilitating Tendon and Ligament Injuries
Historically, the horse with the bowed tendon or strained suspensory
ligament has represented a grave challenge to horsemen trying to
overcome those injuries. Tendons and ligaments, despite the simple
arrangement of the fibers that make them, undergo a complicated
healing process that is further hampered by the simple fact that the
horse, no matter what we do, must continue to use those structures
WHILE healing occurs.
“Dr. Green” (also known as pasture turn-out or time-off) seemed for
awhile to have almost equal success to the various therapies used
for healing tendon and ligament injuries. Veterinarians and horsemen
have used all sorts of counter-irritants, pin-firing, poultices,
injectables, and exercise regimens and other means to achieve the
“healing trinity” of tendon healing.
The healing trinity of tendon or ligament healing from the perspective of
the horsemen may be defined as quality of repair over a shorter time
with complete return to service. Much of the research and effort
currently underway in sport horse medicine is aimed at achieving
that trinity.
Quality of repair is now thought to be improving through use of
regenerative medicine including stem cells, platelet rich plasma (PRP),
autologous conditioned serum (ACS), and extracellular matrix (ECM).
The idea of using these devices for tendon or ligament repair is to
improve quality and reduce time of healing by influencing the body’s
own wound repair process.
Stem cells, when injected into the lesion, are thought to take on the
characteristics of the original, healthy tissue. Platelet rich
plasma, in humans and other animals, has been demonstrated to
decrease pain and reduce time of healing as well as recruit stem
cells into the lesion. Autologous conditioned serum (also known as
IRAP or interleukin-1 antagonist protein) markedly reduces swelling
and pain, and ECM has been shown to provide a scaffolding for
quicker repair. Using these regenerative techniques, alone or in
combination, with tendon and ligament injuries appears to be
improving the recovery rate and return to performance of horses in a
wide range of disciplines.
With regenerative medicine, these lesions appear to heal with more
parallel fiber alignment and similar architecture to the original
tendon (as viewed on ultrasound). Without regenerative medicine,
lesions of the tendon or ligament tend to take longer to heal, with
less parallel orientation of the fibers, and often incompletely,
leaving pockets of fluid surrounded by irregular scar tissue. Such
tendons or ligaments are not as functional as the original,
un-injured organ.
Even with the advances made in the field of regenerative medicine, the
task of rehabilitating the injured horse remains a challenge. Simply
turning a horse out into a pasture or standing it in a stall for
months on end is probably not the answer. Once the tendon or
ligament begins to heal, architectural restoration alone will not
resolve the problem. Those new cells must be conditioned (or
“taught”) to function as well as or better compared to the original.
More importantly, these animals frequently become injured when they are
at the peak of performance and physical condition. The process of
injury, healing, and repair often takes its toll on performance and
condition adding more time to the goal of return to service.
For some time, horsemen have been using swimming pools and underwater
treadmills to maintain physical fitness on rehabilitating horses
while also conditioning the healing tendon, ligament, or other
injury. Swimming pools and underwater treadmills offer “no-impact”
or “low-impact” exercise, and, with veterinary guidance, can be
tailored to the horse and the injury to effect a shorter
rehabilitation period.
A possible disadvantage to swimming-alone is the total lack of impact
during the training. In other words, the horse becomes very fit, but
the healing tendon or ligament does not experience impact. It is
akin to having a very powerful motor in a car with bad tires.
Swimming pools for horses are, however, very important for certain
types of injuries.
Underwater treadmills, however, do allow for some impact while providing
the buoyancy of water, thereby protecting the injured structure.
While underwater treadmills are better at providing some impact,
some are better than others at allowing for control of exercise. One
example of better control is the tank-type, underwater treadmill
(such as the Aqua Pacer). The tank-type underwater treadmill allows
the operator to control not only the speed of the treadmill but also
the depth of the water allowing for a much wider range of motion,
stride length, and greater distribution of muscles actually
affected.
Recently, Steve and Bert McGill installed an Aqua Pacer in their new
facility called the Annadale Equine Center just outside Sanger,
California. According to Bert McGill, the Aqua Pacer will not only
improve the performance of a healthy horse needing condition, but
also may reduce the recovery time for injured horses by as much as
50-60%.
McGill demonstrated the machine to me using a 20 year-old roping horse
that had lost some condition. McGill described the horse before the
conditioning program as a body condition score of 4 out of 10 (just
less than ideal) despite a high plane of nutrition and 45 days of
standard exercise program in the round pen and arena. The horse just
wouldn’t fill-out along the top line or through the hindquarters,
and he lacked stamina and enthusiasm.
After 60 days on the Aqua Pacer, that old rope horse had really turned
the corner with increased muscle and stamina. He is now a BCS 6 and
works out in the Aqua Pacer on almost a daily basis. The change was
impressive and rapid, and appears to be possible for horses
recovering from surgery or soft tissue injury, as well. Thus, the
healing trinity is possible with a quality repair, healing faster,
and returning a fit and sound performance horse back to the arena.
Complimentary to any conditioning or rehabilitation program is the
European-style exercisers. These machines are often automated and
feature the horse standing in a revolving box-stall at variable
rates. Similar in action to the well-known mechanized hot-walker,
the Eurociser is different because the horse moves freely and more
naturally within its box.
In addition to the underwater treadmill, rehabilitation may be enhanced
by hyperbaric oxygen chambers which, when used properly, increase
the amount of oxygen available to injured tissues and therefore
facilitate faster healing.
Of course, the old “tried and true” still work, too. Ice, poultices, and
bandaging are the mainstays of any rehabilitation program.
Conditioning still requires the elbow grease of hand-walking on firm
ground and time under-saddle.
For some horsemen, more is available, of course, when one considers
shockwave, massage therapy, acupuncture, chiropractics, and other
alternatives. While these are often used, and I have seen
improvement in patients using these therapies, the improvement is
sometimes more subjective, at best, to measure.
The real key to achieving the healing trinity for tendons and ligaments
is having a plan and using a teamwork approach towards achieving
results. The owner, trainer, veterinarian, rehabilitator, and
farrier must all have a part, know their part, and communication
between teammates is vital to success. All the fancy equipment and
foul smelling poultices in the world won’t help if a plan isn’t made
and the team doesn’t work, together.
For more information about Annadale Equine Center, please call or write
to Steve and Bert McGill, 17300 East Annadale Avenue, Sanger,
California 93657. (559) 876-3700.
This article was written by Danny W. Dutton DVM, associate
veterinarian at Pacific Crest Equine in Exeter, CA.
"Specializing in Equine Aqua Treadmill Therapy"
Annadale Equine Center
17300 E. Annadale Ave.
Sanger, Ca. 93657
(559) 876-3700
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