The best ice boots for horses provide cold therapy to the lower leg – and are much more effective and less time consuming than cold hosing. They are often used routinely after strenuous exercise in order to support tendons and ligament health (as increased temperatures can cause damage to the structures) or for rehabilitation from injury.

The technologies used in ice and cool boots for horses have come on leaps and bounds – and there is a wide range of options, too. Some ice boots and wraps also provide compression, vibration or the option for heat therapy to offer even further benefits, so it’s important to consider what you hope to get out of your new ice boots.

Consider the practicality of the boots: some cool quickly or without a freezer, others take longer but may last longer. For post-competition use, ensure you have the means to activate and keep them cool.

Best ice and cooling boots for horses

Are ice boots good for horses?

Ice boots can be beneficial to manage injuries and reducing inflammation. Studies have shown that they can reducing swelling and inflammation in a horse’s legs after strenuous exercise.

How do ice boots work?

By constricting blood vessels, ice boots limit the inflammatory response and reduce fluid build-up, helping to speed up recovery from soft tissue injuries. The cooling effect of ice boots can also reduce pain and prevent heat stress after intense exercise.

When using ice boots for horses, it’s essential to ensure a proper fit to cover the targeted area adequately and avoid discomfort. It’s crucial to follow a vet’s recommendations for specific injuries.

How long to leave ice boots on a horse?

Ice boots should generally be left on a horse for 15-20 minutes at a time. This duration is sufficient to reduce inflammation and swelling without risking tissue damage. However, you should always check the individual manufacturer’s guidelines before use.

For acute injuries or after intense exercise, you can apply ice boots multiple times a day. However, ensure that there is a break of at least one to two hours between sessions. Always follow your vet’s specific recommendations to ensure the safe and effective use of ice therapy.

How to use ice boots on horses

• Start by choosing the right size and type of ice boots for your horse, ensuring they will cover the intended area.
• Before applying the boots, inspect your horse’s legs for any cuts or abrasions, and ensure the skin is clean and dry.
• Carefully wrap the ice boots around the horse’s legs, fastening them securely but not too tightly that they could cause discomfort.
• Leave them on for the recommended time while supervising your horse to ensure comfort and proper fit.
• After the recommended time, remove the ice boots and dry your horse’s legs if necessary. Check for any adverse reactions.
• Clean and dry the boots according to the manufacturer’s instructions.

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The discovery that ageing causes significant blood vessel loss in equine tendons could help identify horses at risk of injury and the best way to treat them.

The Royal Veterinary College research considered imaging of the superficial digital flexor tendon, and found that older horses – those aged between 18 and 22 – showed a 70% reduction in vascular volume (the amount of blood present in the tendon blood vessels). They also found a reduction of 30% in vessel diameter, and 74% in the number of vessels, compared to horses aged between two and five.

“This means older tendons receive far less blood flow, making them more vulnerable to damage and slower to heal,” an RVC spokesperson said.

“At the same time, the team observed an increase in the formation of smaller blood vessels within aged tendons, suggesting that the tissue attempts to compensate for the loss of larger vessels. However, this new vascular network appeared disorganised, indicating a loss of vascular balance, so the normal structure and coordination of blood vessels is disrupted. These changes suggest that the new disorganised vessels may not function effectively, reinforcing the need to monitor tendon health closely as horses age.”

The team was led by post-doctoral researcher Nodoka Iwasaki and lecturer Chavaunne Thorpe.

“This study used advanced 3D imaging to reveal, for the first time, how the blood supply to the horse’s tendon changes with age,” Dr Iwasaki said. “We found that older tendons lose many of their larger blood vessels, which are crucial for repair and recovery. This helps explain why older horses are more prone to tendon injuries and why these injuries heal more slowly. We are now exploring ways to prevent this age-related decline, with the aim of improving outcomes for older horses diagnosed with tendon injury”.

Dr Thorpe added that the team is developing methods of slowing the age-related declines, which “if successful, may improve prognosis in older horses diagnosed with tendon injury”.

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Riders are urged to “believe what they feel” and listen to what their horses are telling them, as those often labelled “naughty” or “lazy” may be suffering from suspensory ligament pain, among other potential issues.

Mary Frances, CEO of Moorcroft Equine Rehabilitation Centre in Sussex, has spoken up to highlight suspensory pain as a common cause of issues including unidentifiable lameness and reluctance to go forwards.

“It’s worrying – and incredibly frustrating – to hear of horses who have been simply labelled as ‘naughty’ or ‘lazy’, when in fact they are suffering from suspensory ligament pain and are, therefore, unable to perform adequately,” she told H&H.

“Additionally, in the absence of a correct diagnosis, trainers can often encourage riders to change tack, increase or change feed or ride for longer, blaming a lack of fitness, which can all contribute to the issue and make it worse.”

Ms Frances cited the recent case of a five-year-old mare who had, despite her owner’s best efforts, been “struggling for months with lameness, weakness and behavioural issues” but no issue had been diagnosed. Eight weeks after her arrival at Moorcroft, the mare was comfortable under saddle again.

“Failing to obtain a correct diagnosis can result in serious repercussions, so I would advise any riders or owners with concerns to always seek a second opinion,” she said. “Also, I urge riders to believe in what you are feeling and believe in the feedback from your horse that you truly know very well.

“No horse wakes up in the morning and decides to be ‘lazy’ and not want to work with energy on one rein or the other. We owe it to these amazing horses to listen to them when they struggle with their work. The horse’s welfare is paramount and must be the most important issue at all times. The earlier any condition is identified and treated the better chance of a long-term successful and sound future.”

Possible indicators of suspensory pain include reluctance to go forward, difficulty maintaining straightness, poor engagement and struggling on deep or wet surfaces.

The mare in question was scanned and found to have damage to both rear suspensory ligaments; she underwent a rehab plan involving platelet-rich plasma (PRP) treatment to the ligaments and her sacroiliac area, which is often affected as a secondary issue. She then had strengthening work on long reins.

“Only once the pain and discomfort has been reduced with PRP, can long-reining work begin,” Ms Frances said. “Short, quality long-reining sessions allowed us to strengthen the back and hindquarters without causing damage to the suspensory ligament area. It is essential that the surface the horse works on for this is firm, even and helpful; deep, uneven or irregular surfaces can do even more damage.

“To get the very best results, consistency is key, with the work monitored at all times. Importantly, for this type of injury, straight line work is more beneficial than circles.”

A spokesperson for Moorcroft added: “The mare’s transformation was evident within weeks. Her posture improved, her movement became fluid, and she was once again able to carry a rider with ease.”

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British showjumper Graham Gillespie and the hugely successful stallion Warriors Glory jumped to a fairytale grand prix victory on (Saturday) 8 February.

The landmark win was a remarkable comeback for the 16-year-old stallion, known at home as Gorilla, who was retired from the sport in 2023 with a serious tendon injury.

“I’d only recently started riding him when the injury happened out in Vilamoura,” Graham told H&H. “It was quite bad and we didn’t have too much hope for him at that point.”

Gorilla’s owner and Graham’s business partner, Sean Cubitt, said, “Two vets told us he would never jump again. We found this company in Holland called Equi Laser and at first I thought, ‘That’s never going to work’. But we took him there for six weeks and they kept him for 14 months! The guy rode him every day, treated him like a normal horse, took him out into the field and lasered him every day.”

The innovative Equi Laser treatment is said to involve “five patented wavelengths” to “produce a combination of anti-inflammatory, pain relief and bio-stimulation of tissues, which causes regeneration”.

Graham Gillespie on Warriors Glory’s comeback: “What they did for him was incredible”

Graham started bringing the Brendon Stud-bred stallion (Warrior x Caretino Glory) back into work three months ago.

“What they did for him was incredible,” said Graham. “They were always very positive about his recovery.”

Graham’s first show back with Warriors Glory came at Oliva at the end of January before they stepped up to the CSI4* classes on the Andalucia Sunshine Tour in Vejer de la Frontera, Spain.

“He just did a lot of roadwork and hacking in the early days, then he did a few 1.30m classes at Oliva and he ended up finishing second in a 1.45m there,” said Graham. “By the time he came to Vejer, he was ready to rock and roll!”

“I’ve never given a fist pump in my life, but I had to let one go this time!”

In Saturday’s CSI4* Tesalia 1.45m small grand prix, Graham Gillespie and Warriors Glory swept to victory from an advantageous final draw in a high-calibre 13-way jump-off, edging ahead of French showjumper Penelope Leprevost and Djagger Semilly by 0.03sec. James Whitaker and Just Call Me Henry completed the rankings class podium in third.

“What a retirement!” said Sean of his horse’s remarkable comeback.

“There were a few good names in the jump-off,” said Graham. “We had a little plan drawn up and we managed to execute it. It was great. Diving through the finish with the screen on my right showing the green numbers was brilliant. I’ve never given a fist pump in my life, but I had to let one go this time!”

Warriors Glory has jumped successfully up to five-star level with a string of leading international riders and is now “back where he belongs” said Graham of the son of 2012 Olympic contender Warrior.

“Gorilla is just a winner – that’s what he’s always done, it’s his thing, so it’s great to be a part of his amazing journey once again.”

Graham has several other horses with him on the tour, including top ride, the 17-year-old Veneno, who will hopefully be back in grand prix mode this week, paving the way for a very exciting year ahead.

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Norwegian rider Victoria Gulliksen jumped clear in the Agria FEI World Showjumping Championships today — on a horse vets said was “finished” when he sliced open a tendon in an aeroplane accident.

Victoria, daughter of showjumping legend Geir Gulliksen, and 13-year-old Equine America Papa Roach put in a class round to sit in 31st place after the opening speed round.

Victoria has had the ride on the “very talented” Perigueux x Zeus gelding since he was six, and said he had started jumping some big tracks by the time he was eight.

“Then when he was 10, unfortunately he had a very, very bad accident,” she said. “He was flying home from Athens; we had won and qualified for the [Global Champions Tour] Super League. A metal piece came loose in the plane and cut through his whole back tendon.

“All the vet said ‘Your horse is finished. It’s never coming back. It’s done.’”

But, Victoria said “Pappy”, as he is known at home – “Or Lipsy, because he’s got very big lips!” – is a fighter, and after 21 months, he was back in competition, jumping at last year’s Europeans en route to the World Showjumping Championships.

“We took a very long time; we went hacking in the woods a lot, just hacking,” she said. “And then he came back and we did it very slowly. So for me when I go in the ring, every round is a bonus because he was supposed to [be retired] in the field.

“He was a very good boy today; he saved me a lot. He does when I put him far off and close, he always tries. He was trying hard to do the jumps perfectly and I’m very, very happy.”

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The owner of a pony who damaged ligaments so badly, her fetlock was displaced has urged others not to give up hope, as she is back in the saddle a year later.

Michelle Clark’s Welsh section D mare Thornynewside Rambling Rose was given a poor prognosis after the field accident in December 2020, and Michelle was advised to put her down — but she has now been back in ridden walk work for two weeks.

“She’s made such an amazing recovery,” Michelle told H&H. “I can’t explain how it felt to get back on.”

Michelle had loaned “Luna”, who is now eight, to a college to continue her education, as her job as a carer meant she had limited time. It was on Boxing Day she was injured in the field.

“The vet thought she might have gone down a hole and turned, as she’d completely ruptured both ligaments on one side of her fetlock,” Michelle said. “He could manipulate the bone out of place, and Luna was on three legs.”

Luna went to Liphook equine hospital, where scans revealed the extent of the damage.

“At that point they said the worst case was that it would never heal and she’d have to be put down,” Michelle said. “People were telling me I should put her down, but I couldn’t do that.”

Luna was fitted with a cast, and was on box rest for six to seven months.

“Another miracle was when the vet came to take the cast off; he said don’t be shocked because there will be loads of bruising and sores but there was nothing,” Michelle said.

“I take my hat off to the vet for the job he did, and although he said she’d need it on for eight to 12 weeks, in the end it was only six.”

Luna then got the all-clear to go out, at the end of last summer. Michelle believes the course of indiba, or radio frequency, treatment she had helped, as scans before and after the course showed a significant improvement, and also feeding to boost her chances of healing well.

“The vet said she was looking great,” Michelle said. “And when I got on her again, I bit the bullet and took her out. Before the injury, she used to be spooking at everything but she was like a different horse so I think the time off helped her.

“To go from thinking I’d lose my best friend to this; I can’t explain it. But I want people to know not to give up hope.”

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Stay in touch with all the news in the run-up to and throughout the major shows and events during 2026 and beyond with a Horse & Hound subscription. Subscribe today for all you need to know ahead of these major events, plus online reports on the action as it happens from our expert team of reporters and in-depth analysis in our special commemorative magazines. Have a subscription already? Set up your unlimited website access now

The owner of a 23-year-old mare who has twice fought back from career-threatening injuries said it means “everything” to have her happy and in work again.

Lindsey Templeman’s Anglo Arab Summer Day had been “remarkably accident- and problem-free” in the 15 years she had owned her, until she suffered badly damaged ligaments in an accident last year.

Lindsey told H&H Summer had been moved into a paddock containing a tractor and trailer.

“She must have gone round the back of it,” Lindsey said. “She doesn’t look for trouble so I think one of the others must have wandered round and blocked her exit, and where the trailer narrowed, she must have thought ‘I can jump that’, but she caught her stifle on the two metal bits.”

The resulting cuts seemed superficial and although there was swelling, Summer was sound.

“The lameness didn’t come for a week or so,” Lindsey said. “Where she caught her leg, she must have twisted as she tried to get free, and had damaged two ligaments.”

Lindsey was told there was a “strong chance” Summer would not recover. She was on box or small-paddock rest for 12 weeks, after which Karolina Kalka, of Seadown Equine vets, was not happy with her progress.

“Karolina said this [polyacrylamide] gel was the only thing that might make a difference, but there was no guarantee,” Lindsey said. “She only had about 5ml injected into the stifle — and I was riding her about six weeks later. I was trotting her and Karolina said ‘You’d never have known there was anything wrong with her’.”

Lindsey and Summer enjoyed a winter and spring of riding, until this June.

“I suddenly thought something wasn’t right,” Lindsey said. “I thought it might be because of her age but when Karolina scanned her, she said ‘Oh goodness. How much do you want to spend?’ Her suspensory ligament had several lesions, and Karolina said if we left it, it could fail.”

Lindsey was given a less than 50% chance of Summer returning to work at her previous level. The mare was rested in a small paddock, as she had not coped well with box rest, and the decision was made to treat her with stem-cell therapy.

But when two shipments of the cells were unusable as they had got too warm in transit, the vet used IRAP (Interleukin-1 receptor antagonist protein) instead.

This is a system used to obtain multiple anti-inflammatory and regenerative proteins from a patient’s blood, and Seadown bought the necessary equipment as there was no facility nearby.

“The IRAP was always the next best option but when Karolina scanned Summer, she found she’d started healing by herself, with no treatment; even without box rest, it was straight and everything looked healthy,” Lindsey said. “She injected the IRAP into the lesions and whatever it was we did, it worked amazingly.”

Summer is now back to hacking, and short canters, with no swelling or evidence of any issues.

“This is a 23-year-old mare who’s had two major injuries, and normally the rule is six months’ box rest but she went straight out,” Lindsey said. “It begs the question: is box rest the right way to deal with these injuries? The vet said she’d healed far beyond what she’d have expected even in a young horse.”

Lindsey praised her “amazing” vet, who went “above and beyond” throughout, to get Summer right and keep the cost down.

“She’s almost back to normal now and it means everything,” she said. “I don’t think you realise; you take for granted things like riding in the forest, until, twice for me, I’ve realised it might all be taken away.

“I’m 60 now and she’ll be my last horse, and I hate the idea of her being stuck in a field, but I can tell from the way she moves that she’s feeling really good.

“She looks brilliant, and I’m extremely lucky. Summer is my one in a million horse and she deserved every possible chance.”

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Stay in touch with all the news in the run-up to and throughout the major shows and events during 2026 and beyond with a Horse & Hound subscription. Subscribe today for all you need to know ahead of these major events, plus online reports on the action as it happens from our expert team of reporters and in-depth analysis in our special commemorative magazines. Have a subscription already? Set up your unlimited website access now

The suspensory ligaments play a vital supporting role in athletic movement, so what’s the prognosis when damage occurs? Dr Rachel Murray MRCVS discusses outcomes

Running down the back of each cannon bone is the suspensory ligament, the tough, fibrous structure that supports the fetlock when the limb is loaded. The ligament starts just below the hock or knee and splits into two branches closer to the fetlock.

With the advanced imaging modalities now available, such as magnetic resonance imaging, we are more aware that not all suspensory ligament injuries are the same. Pain can come from the ligament and the bone where the ligament attaches – the cannon bone at the top and the proximal sesamoid bones at the bottom.

Suspensory ligament injuries may be caused by a sudden-onset single incident or repetitive overload. Damage at the top, or “origin”, of the ligament (proximal suspensory desmitis) is a risk in the hindlimb of the dressage horse, but possible in any sport. Damage in the middle, or “body”, usually occurs as an extension of injury at the origin or branches. Branch injuries may be caused by a twisting hyperextension of the fetlock or by direct trauma.

Certain conformational features and movement patterns may be associated with suspensory injury. A horse with a tendency to repeatedly and excessively extend his fetlock joints is at increased risk, which is related to his natural conformation and movement, the sport he does or his training.

Research shows that horses with straight hock conformation are more likely to have suspensory ligament injuries, due to hyperextension of the fetlock during locomotion. This places greater strain on the suspensory ligament, increasing risk of injury or reducing chances of recovery.

A horse trained to perform and repeat movements for which he does not have adequate muscle strength, endurance, flexibility or fitness will use the “wrong” muscle patterns and overload parts of his body to compensate for weakness. This can be exacerbated by poor core stability, placing strains on the lower limbs – including the suspensory ligament. Young horses with extravagant movement are particularly vulnerable: the “bigger” (faster or more extended) the trot, the more the fetlock drops and the greater the strain.

Treatment options

Early treatment of suspensory injury can lead to good recovery. However, some long-term or severe injuries can be frustrating to treat and difficult to manage.

Treatment is determined by many factors – where the injury is located, whether it is recent or involves longer-term scarring, if it affects bone and soft tissue, and any concurrent injuries. The horse’s age, conformation and sport must also be considered.

A severe bone injury is likely to need rest and hand-walking as part of a controlled rehabilitation programme. A mild bone injury may respond well to reducing the frequency and quantity of training, giving the bone time to recover between sessions, but still stimulating it sufficiently to repair the injured area.

Rest and controlled exercise alone can be a reasonable option for active branch injuries and forelimb proximal suspensory desmitis, depending on the severity of the injury, the horse’s age and the injury location. This may be less effective in hindlimb proximal suspensory desmitis, although I have had some good results rehabilitating young horses this way and following long-term turnout, particularly on hills.

High-intensity laser therapy has recently become available for horses and can help to reduce inflammation and promote healing in injuries of the branches, body and origin. Treatment with biological agents, including PRP (platelet-rich plasma), IRAP (interleukin-1 receptor antagonist protein) or stem cells, may also promote healing.

For horses with longer-term, chronic suspensory injuries, managing pain associated with scarring and repetitive strains at the attachment of the ligament becomes important. Extracorporeal shockwave therapy can be effective in removing pain and allowing the horse to move normally, alongside a programme of muscle development and ligament protection.

Horses with proximal suspensory desmopathy (a less inflammatory condition) who do not respond to other treatment, or those with chronic hind suspensory injury, may require surgical treatment. This can include resection (removal) of the tight band of tissue around the suspensory ligament, to help the ligament repair, or resection of nerves supplying this area, or both.

If surgical cases are carefully selected, it has been reported 78% can return to full work. But recent research and clinical experience suggests horses with a dropped fetlock or straight hindlimb conformation or both may not be good candidates for surgery.

Team tactics

At our clinic, we’ve found that a team approach to management can maximise recovery.

Eliminating pain helps prevent abnormal movement patterns that could have predisposed the horse to initial ligament injury. Retraining movement requires the development of correct neuromuscular pathways and the building of muscle strength and stability, which is a critical part of rehabilitation. Since the horse’s posture and core stability are key, the involvement of an Association of Chartered Physiotherapists in Animal Therapy (ACPAT) physiotherapist, who can work alongside the vet in the rehab process, is recommended.

Shoeing to support the ligament and help movement patterns is essential, tailored to the horse’s conformation and sport, as well as the surface on which he will be moving. A stable base reduces “wobble” of the leg, hock twisting and uneven fetlock extension, protecting the suspensory ligament. Increased support on the side of a branch injury will also help.

Careful management can be used to minimise the risk of re-injury. The more uphill and extravagant the horse’s movement, the more care must be taken. Both rider and trainer should recognise the importance of cross-training, core muscle development and avoiding over-repetition of exercises when a horse is tired.

Suspensory injury is a complex condition. There is increasing evidence that the best outcome relies upon a holistic approach, managing the biomechanics of the entire horse – and not just the ligament.

Steps to soundness

Charlie, an eight-year-old, advanced medium-level dressage horse, had always been slightly uneven in the contact and less keen on bending right. Following a hard training session, he developed swelling and heat on the outside of a lower forelimb and was unlevel when trotted in hand. The leg was treated with ice, cold hosing and pressure bandaging.

An ultrasound examination found swelling and active damage to the lateral (outside) suspensory branch, with some mild, long-term abnormality at the ligament attachment onto the proximal sesamoid bone at the fetlock. A combination of high-intensity laser therapy and cold treatment was chosen, along with shoeing to support the outside of the leg. Charlie’s physiotherapist had the job of teaching him to use his body more evenly, using stable exercises and ground work with specific training aids and tailored pole exercises.

A repeat ultrasound exam after six weeks showed considerable improvement. Controlled exercise was gradually increased, with check-ups to decide the pace at which to resume training.

Charlie is now back competing – achieving 72% in his first competition and winning at prix st georges. He feels more even in the contact, with improved lateral movement and quality of work, now that he is using his body more effectively.

The vet: Dr Rachel Murray is a veterinary specialist with particular expertise in advanced diagnostic imaging, poor performance and rehabilitation of sport horses. Rachel is based at Rossdales Equine Hospital and Diagnostic Centre in Newmarket, working in a team of sport horse clinicians. This world-renowned hospital sees horses and ponies from throughout the UK for diagnostic, medical, surgical and reproductive referrals. 01638 577754/rossdales.com

Ref Horse & Hound; 17 September 2020

A study of injuries in racehorses has revealed that geldings are three times more likely to suffer superficial digital flexor tendon (SDFT) damage than mares or stallions.

The research, conducted in Japan, demonstrated a string of other risk factors for SDFT injury, with horses finishing 10th or lower in a race (2.5x) and a gap of more than 90 days between runs (1.75x) among the most significant.

The report by Yoko Ikeda, Akikazu Ishihara, Masahiko Nakajima and Kazutaka Yamada, published in the Japanese Journal of Equine Science last month, looked at SDFT injuries as they are very common in racing thoroughbreds. Musculoskeletal problems account for the retirement of 76% of racehorses in Japan, 46% of these down to SDFT problems.

Taking data from the medical records of a racetrack, researchers discovered a list of risk factors for tendinopathy that also included “sloppy” (heavy) tracks (1.7x), races shorter than 1300m (1.40x) and horses placed eighth or lower in the betting (1.49x).

One risk factor specifically associated with the characteristics of the racehorses themselves was bodyweight, with those sustaining SDFT injuries significantly heavier than the control horses. Those above 470kg were most at risk.

An interesting finding was that when there was a decrease in bodyweight since a previous race, the SDFT tendinopathy risk was also “significantly high”.

“This result suggested that muscle loss or too much training load before the race also worsens general conditions,” the researchers said. “Hence, these horses experience muscle fatigue earlier than fit horses, resulting in increased tendon forces toward the end of race and thus a risk of SDF tendinopathy.”

They cautioned that the data for bodyweight could be conflicting, however.

“Decreased bodyweight could not only be the result of muscle loss or excessive training but also be the result of intentional weight reduction during training to improve race performance. Our study did not include any survey to assess the intent of previous trainings, and our results were not sufficient to draw any conclusions with respect to these arguments,” they added.

Continues below…

Riders think they know more than they do, research shows

‘This over-confidence can have serious consequences on the welfare of horses, and could affect the mental health of riders’

Top scientists make breakthrough in stem cell research for tendon injuries

Researchers are hopeful the breakthrough could lead to new and improved treatment methods for tendon injuries in horses

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While one previous study contradicted some findings — showing mares, firm track surfaces and older horses to be high-risk factors — the results of this research clearly showed colts and geldings to be at “significantly higher risk”.

“Such a phenomenon would, in turn, demonstrate that the lowest risk of SDF tendinopathy is in female horses, indicating that the slower gait velocity in female horses could potentially reduce the tendon strains,” the report said.

It also highlighted the problem of accumulated micro-damage caused by short, fast races and recommended that in order to prevent tendon injuries, a sloppy track should be avoided and that the safest runs were long-distance and with a slower speed.

The study involved 292 racehorses diagnosed with SDFT tendinopathy between 2011 and 2015. Two control horses were matched to each case horse by randomly selecting from those who were not included as case horses, had the same trainer, had started a race within six months of injury in case horses and were of the same age as the case horses.

“Further investigations with larger sample sizes are warranted to clarify the positive or negative impact of decreases in body weight and the length of the race interval on the risk of SDF tendinopathy,” the report concluded.

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• This article has been edited and approved by Karen Coumbe MRCVS, H&H’s veterinary advisor since 1991.

When my thoroughbred eventer’s minor tendon tweak turned into a potentially career-ending tendon injury, I was devastated. But thanks to the excellent advice and care of Ricky Farr MRCVS of Farr & Pursey Equine, combined with use of the Equestride support boot and sticking to a strict horse tendon injury rehab plan, my horse not only returned to work, but he was able to compete and jump on a surface once again.

A horse tendon injury rehab plan – a diary lasting 52 weeks

20 September 2016: A couple of days after a successful BE100 run, Dennis feels slightly off in trot, on the near fore, while hacking on the road. There is no obvious heat or swelling and as he has suffered from bruised soles before, I give him a few days off.

26 September: he feels unlevel again so I call the vet. There is nothing notable to see or feel, but hoof testers confirm bruising to the sole and a week off work is prescribed.

30 September: after pulling some impressive acrobatics while turned out, Dennis is found looking sorry for himself, not grazing or moving, and he has an obvious soft tissue injury in the near fore below the knee. He is prescribed Danilon, plus five days’ box rest with ice and cold hosing multiple times a day to reduce the swelling.

5 October: the swelling has gone down enough to scan the injury, which is located towards the top of the superficial digital flexor tendon. An ultrasound shows a disruption in the tendon fibres, but no core lesions and my vet is fairly upbeat. Danilon, box rest, cold hosing and bandaging continue.

24 October: a significant setback. An incident on the yard leads to the leg blowing up considerably. We return to more aggressive levels of cold therapy and prepare for further scans to assess the damage.

2 November: scans show the tendon is splitting and forming a mushroom shape as the fibres peel away from each other. The prognosis is now far less positive. Dennis is insured for vet fees, but the injured leg is excluded, limiting treatment options. We begin the topical application of a gel with anti-inflammatory properties, and an analgesic to reduce the swelling. Box rest and bandaging continues.

11 November: a scan shows core lesions have formed within the tendon. We discuss treatment options, costs and the long-term prognosis. Ricky feels the tendon will benefit from some “scaffolding” to kick-start the healing process. At this stage it looks unlikely that we will return to jumping in any form, but if we can enjoy dressage and hacking I feel that would make the treatment worthwhile. Stem-cell therapy is financially out of reach, so we go ahead with an injection of platelet-rich plasma (PRP) therapy into the lesions. This treatment can be carried out at home, avoiding the risk of further injury in transit and any hospitalisation costs.

21 November: Dennis is sedated and blood taken from a vein in his neck. The blood is run through the PRP filter kit and then the PRP solution is injected into the lesions in the tendon. The leg is heavily bandaged and left for a few days to let the treatment take effect. This heavy bandage is then replaced with standard support bandages to keep the leg warm, supported and clean. Dennis is on box rest for one week. We order an Equestride support boot, designed by Andrew Daly, to reduce the chance of reinjury during the rehab period.

28 November: Dennis starts walking out in-hand, for 10 minutes daily, wearing stable bandages. We walk on a large circle around the yard, which has a non-slip surface, regularly changing direction.

5 December: walking increases to 15 minutes. We decide that sedation is necessary to avoid reinjury of the tendon (and keep his handlers safe) while waiting for the Equestride boot to arrive.

12 December: walking increases to 20 minutes. I’m praying the Equestride boot arrives soon as even with sedation, walking in-hand is like flying a horse-shaped kite.

19 December: an Equestride boot arrives to coincide with Dennis’ next scan. Ricky is pleased with the scan, fits the boot and walking under saddle begins. We start using the boot on setting two, which allows some loading of the injured tendon while providing support to prevent putting the damaged structures under too much stress.

26 December: walking increases to 25 minutes wearing the Equestride boot. Stable bandages are no longer required in the stable. Sedation is required for ridden work, which is mainly in straight lines on a firm surface.

9 January 2017: walking for 30 minutes now, mostly in the school under saddle. Otherwise, walking is done in-hand on the yard split across two sessions a day.

6 February: walking for 40 minutes a day and we begin hacking, still wearing the Equestride boot on level two. I’m very grateful for it as Dennis produces some significant aerial manoeuvres on the road.

27 February: the ultrasound scan shows good progress. A further four weeks of 40 minutes’ walking a day, incorporating five minutes of trot work, follows.

27 March: 35 minutes’ walking with 10 minutes’ trotting for four weeks. My vet advises reducing the Equestride boot to setting one, which increases the load on the injured structures. I introduce in-hand grazing for short periods. Dennis is very pleased to eat grass again!

8 April: he is turned out loose for the first time in six months in a paddock only slightly bigger than his stable. I’m delighted that his stomach wins out and he’s more interested in grazing than leaping about. He is still wearing the Equestride boot for turnout and exercise.

24 April: 30 minutes’ walking and 15 minutes’ trotting for four weeks, gradually increasing turnout time.

11 May: another scan and it’s good news — Ricky is happy with progress.

22 May: We are up to 25 minutes’ walking and 20 minutes’ trotting daily under saddle, with the turnout paddock increased to 10 times stable size.

5 June: we introduce short canters in the school, a couple of weeks earlier than advised by the Royal Veterinary College’s rehab programme, which is designed for injured National Hunt horses, because the Equestride boot is due to be returned soon and I want to have it on for our first few canters.

19 June: the Equestride boot has been returned. We reduce the walk but increase trot periods, plus include five minutes’ canter, for two weeks.

3 July: 15 minutes’ walk, 20 minutes’ trot and 10 minutes’ cantering for the next four weeks.

27 July: The tendon still shows residual signs of damage both on the scan and externally, but Dennis is coping well with his workload; the leg is cold and hard and he is showing no signs of discomfort while working or on palpation.

August: Dennis makes his British Dressage (BD) debut and qualifies for the BD thoroughbred championships at prelim level.

18 November: We head off to Vale View for the BD thoroughbred championships and return home with first place in the warm-up class and third in the prelim championship. Brought home our first BD plaque, which I’m very proud of.

25 February 2018: Head to Addington for the BD winter regionals at prelim level. Our test rather split the judges but we collected another BD plaque to go alongside his TB one.

22 March: I’m keen to advance Dennis’ training on the flat so we can have a go at some higher level dressage in time. We had our first attempt at flying changes but he got quite hot/tense, so we left the idea there for him to mull over at his leisure.

6 May: took Dennis to the gallops to accompany a young horse, and had a couple of steady canters. Iced afterwards.

19 May: decided to bite the bullet and popped Dennis over some small fences for the first time since his injury. He was a very happy boy. Iced afterwards. Continued to jump only on a good surface and always icing afterwards.

24 June: First competitive jumping outing since his injury. Headed to Quainton Stud for the 80cm combined training. Happy days. Iced and cold hosed the legs after. No heat or swelling the following morning.

14-15 July: I had booked my young horse in to attend a two-day eventing camp at Boomerang, but as he couldn’t go I decided to take Dennis and just do as much as I felt was wise at the time. We were in the 80cm group, kept the jumping to a minimum and only on a surface, and iced after every session. Dennis loved being away and was a very happy chappy throughout. Was good fun and I was glad I went.

21 August: Take a very deep breath and head at Attington for our first time jumping solid fences since his injury. I’m still terrified he’s going to break, but it’s as if he’s never been away. I’m far more rusty than he is and afterwards I don’t know which of us is happier. Will admit to a few happy tears in the lorry afterwards. Iced before travelling home and cold hosed when we got back.

30 September: First competitive elementary dressage test and scored 69.67%

13 October: Won the 80cm combined training championships at Quainton Stud. First time we’ve ever won a sash! More ice.

9 December: Arena Eventing at Keysoe. Finished fourth in the BE80 class. More ice.

15 December: On my request, Ricky rescanned the leg two years on from the PRP. There has been further significant improvement in the tendon fibres since the previous scan some 18 months earlier. At the time, Ricky felt we might have had all the healing that was going to happen, but the remaining shadows have pretty much disappeared and the fibre pattern is also looking improved. There is a still a little bit of ragged edge where the mushroom shape was, but the shape of the injury site is much closer to what you’d expect to see. On external view the tendon is looking much tighter and the thickening has significantly lessened.

January/February/March 2019: Further visits to Attington and Aston-Le-Walls confidently jumping a range of fences up to BE100 level heights and questions. More ice (are you sensing a theme here?)

Summer 2019: I moved yards at the end of March to a place with a wider range of hacking, including more opportunities to canter and pop some small solid fences on grass. I started by introducing short steady cantering on good grass going out hacking, and have popped a few small logs. While I have been sorely tempted to go cross-country schooling and do some unaffiliated eventing (and don’t rule out doing so in the future on good ground) I haven’t done so yet. I ice his injured leg religiously after jumping or cantering on grass. At the moment his leg remains cold and hard at all times, so I feel the current work regime is suiting him physically and he seems happy so long may it last.

A quick note on shoeing: throughout his rehab and since his return to work, Dennis has not received any remedial shoeing, although my farrier always ensures his feet are as well balanced as possible and shoes him to provide plenty of support to his heels. We did not shoe him with wedges or graduated shoes during his recovery.

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Stay in touch with all the news in the run-up to and throughout the major shows and events during 2026 and beyond with a Horse & Hound subscription. Subscribe today for all you need to know ahead of these major events, plus online reports on the action as it happens from our expert team of reporters and in-depth analysis in our special commemorative magazines. Have a subscription already? Set up your unlimited website access now

• This article has been edited and approved by Karen Coumbe MRCVS, H&H’s veterinary advisor since 1991.

Suspensory ligament injuries in horses can affect the animal’s future athletic ability. In order to understand why and how injuries occur, it is helpful to be familiar with the structures involved.

Ligaments attach bones to each other and act as supports. The suspensory ligament in the horse is a strong, broad, fibrous anatomical structure that attaches to the back of the cannon bone just below the knee or hock — the origin of the ligament.

About two-thirds of the way down the cannon bone, the ligament divides into two branches which attach to the inside and outside sesamoid bones, on the back of the fetlock.

In the upper third of the cannon region, the suspensory ligament lies between the large “heads” of the splint bones. This means it is impossible to feel the ligament, or apply pressure directly to it, so diagnosis of damage here is difficult.

Sprain of the suspensory ligament (suspensory desmitis) is usually restricted to one of three areas:

• injury to the upper third of the ligament (called high, or proximal, suspensory desmitis) is common in horses in all disciplines
• injury to the middle third, or body, of the ligament is easiest to diagnose, but least frequent. National Hunt racehorses and point-to-pointers are most likely to suffer this injury, called body desmitis.
• damage to the inside or outside branch of the suspensory ligament is also common, particularly in horses which jump, called branch desmitis.

Suspensory ligament injuries: Signs | Treatment | Prognosis | High risks

Signs of suspensory desmitis

A ligament sprain causes heat, swelling and pain. When the middle third, or body, of the suspensory ligament is sprained the signs are easy to detect as there is often obvious swelling that can be seen on both the inside and outside of the injured leg.

Heat is easily felt on close examination of the limb. The horse will also resent palpation of the injured part of the ligament, the edges of which may be rounded and poorly defined. The ligament may feel softer than normal.There is usually some lameness, the degree of which often reflects the severity of the injury. However, lack of lameness does not mean there is no significant injury. With a severe injury, the whole area may be swollen so it can be difficult to assess which part of the ligament is primarily involved.

Cold therapy and bandaging will usually reduce the swelling, making a definitive diagnosis easier. Once the injured soft tissue structure has been identified, your vet can assess the extent of the damage using an ultrasound scanner, however this is often easier for body or branch lesions than clearly imaging proximal suspensory lesions by ultrasound.

An injury to the inside or outside branch of the ligament will cause swelling on one side of the fetlock. Take care not to confuse this with a swelling due to direct trauma, such as getting cast.

Lameness associated with a branch injury can be mild to moderate, but may improve within days. Again, scanning will confirm the extent and severity of the injury and determine whether there is also damage to either the sesamoid bone or the splint bone on the same side. X-rays may also be useful, particularly to check for splint bone fractures or sesamoid bone damage, which can be associated with a suspensory ligament branch injury.

Damage at the proximal part or top of the suspensory ligament invariably causes lameness — varying from mild to severe — which, if the horse rests, can improve rapidly. The lameness tends to be worst when the horse moves in circles with the affected limb on the outside. Slight localised heat may appear when the lameness is acute and sometimes the vein that runs down the inside of the cannon region may be enlarged.

In many cases there is nothing abnormal to feel and the vet may use a nerve block to eliminate the lower limb as a source of pain and also determine that the pain is coming from just below the back of the knee.

Imaging the damaged area is key. Sometimes an obvious black hole in the ligament shows up on the scan; sometimes the changes are more subtle. The ligament may be slightly enlarged, with just a tiny disruption of its fibre pattern. X-ray changes may be apparent in a few cases. Research has shown that high field MRI is considered the gold standard for diagnosis, but is rarely performed as a general anaesthetic is required and the equipment is only available in a few specialist centres, instead fastidious and thorough ultrasonographic imaging is required.

Treatment of a suspensory injury

The vet will seek to eliminate any predisposing causes such as poor foot balance or inappropriate shoes; reduce inflammation by the use of cold therapy, laser treatment or therapeutic ultrasound; and to encourage good quality repair of the damaged fibres. Scanning can be used to monitor the healing.

The exact type of treatment will vary depending on the area of damage,

Shockwave therapy has been successfully used for cases of proximal suspensory desmitis (PSD) and some suspensory body lesions.

Use of injectable therapies such as PRP (platelet rich plasma) or stem cells may be used in suitable cases. They may not help to alleviate the pain causing the lameness.

Surgery in the form a neurectomy to relieve the pain, together with cutting specific soft tissues (fasciotomy) has been used successfully in both hind and front legs for proximal suspensory lesions. Some suspensory ligament branch injuries will also require surgery, if there is damage within the fetlock joint. In one report this helped 13/18 horses to recover.

Prolonged rest combined with an ascending exercise programme is an essential part of any treatment regime for any suspensory ligament injury.

Prognosis after suspensory ligament injuries

This depends on many factors including:

• the site of the injury
• its severity
• the duration of the injury
• the future athletic expectations for the horse

Most horses are able to return to some level of work.

For proximal suspensory lesions the overall prognosis for return to exercise is better in the forelimbs (about 80% resolve), whereas hindlimbs can be more problematic with less than 20% recovering, however shockwave therapy and surgery improve the chances of an injured horse returning to work.

The chance of repeat damage to injuries on the body of the ligament is quite high if the horse returns to its former workload. The prognosis for branch injuries is guarded because of the high incidence of reoccurrence and the slow unpredictable rate of healing.

Which horses are most at risk?

Some factors may predispose the horse to suspensory ligament injuries or their recurrence.

• conformation can play a role – a horse with a crooked lower limb will overload one side of the fetlock and predispose it to a branch injury
• poor foot balance is commonly seen in horses which injure the origin of the ligament. If the shoes are too short and offer little support to the back of the heel region, this can cause overload of the ligament
• dressage horses are at risk from damage to the hindlimb origin as a result of repetitive overloading during training for collected work and tissue degeneration.
• suspensory ligament injuries are an occupational hazard for horses that do regular fast work and jump at speed
• a previous suspensory injury places a horse at increased risk of repeat injury since, particularly with body and branch injuries, the repaired tissue is never as strong as before

References:

https://onlinelibrary.wiley.com/doi/abs/10.1111/eve.13187 – An investigation into the occurrence of, and risk factors for, concurrent suspensory ligament injuries in horses with hindlimb proximal suspensory desmopathy – October 2019

• This article has been edited and approved by Karen Coumbe MRCVS, H&H’s veterinary advisor since 1991.

Tendon injuries in horses can signal the end of an equine’s athletic career, although there are many horses that successfully return to riding, and competition, albeit sometimes at a lower level, after appropriate treatment and a significant recovery period.

Tendon injuries : Causes | Signs | Diagnosis | Treatment | Prognosis

In order to understand why and how these injuries occur, it is helpful to be familiar with the structures involved.

Tendons are the straps of connective tissues that attach a muscle to other body parts, usually bones. They transfer the force of muscle contraction to the bones enabling movement; the tendon is firmly connected to muscle fibres at one end and to components of the bone at the other end.

While tendon injuries are a common problem in horses, tendons are actually remarkably strong, with relatively high tensile strengths for a soft tissue. Their great strength is due to the impressive anatomical structure and tissue composition of the tendon fibres. They contain many collagen fibres running in parallel orientations.

The tendons in the horse’s lower leg include:

• the extensor tendon at the front of the leg
• the superficial digital flexor tendon at the back of the leg
• the deep digital flexor tendon located at the back of the leg between the cannon bone and suspensory ligament, and the superficial digital flexor tendon

Causes of tendon injuries

A damaged tendon occurs when the tendon is strained, which is when the fibres within the tendons in the lower leg are overloaded (internal damage) or when they suffer an impact injury (external damage). Typically the individual tendon fibres are broken, similar to an old rope fraying. When this happens there is a large inflammatory response with swelling around the injury and the horse is likely to be lame.

Tendonitis is the term that is use to describe a tendon strain and this can vary from a minor tweak to a few tendon fibres to a major disruption of the whole structure.It is important to be aware that the degree of lameness is not necessarily related to the amount of damage to the tendon. Confusingly, some horses can have quite extensive damage without being very lame, or the affected limb being very swollen. Equally, subtle thickening may be related to substantial tendon damage.The superficial digital flexor tendon in the foreleg is where most tendon injuries occur, ranging from a mild strain to a complete rupture of the tendon. The deep digital flexor tendon is also at risk of injury, while injuries to the extensor tendon are far less frequent and less severe when they do occur. The advent of MRI has meant that tendinitis of the deep digital flexor tendon is now a much more commonly diagnosed problem at the lower end of the tendon to within the horse’s foot.Vets generally describe tendon injuries by three levels of severity — mild, moderate and severe — and generally the more severe the damage, the poorer the prognosis.

Signs of a tendon injury

• Heat at the site of the injury
• Swelling around the site of the injury
• Lameness of varying severity
• If the deep or superficial flexor tendon is completely ruptured, the fetlock will drop towards the ground

Diagnosis

When diagnosing a tendon injury, your vet will begin by palpating the swollen soft tissues around the cannon bone to identify which structure is involved.

To confirm the extent of the damage, ultrasound imaging will be used so the vet can visualise the extent of the damage within the tendon. The initial swelling will need to have subsided to get a useful scan of the injury so this normally takes place around one week after the injury occurred.

While waiting for the scan, the standard recommendation is that horse should be kept bandaged on box rest, with frequent cold therapy in the form of cold water or ice boots applied to the injury to help reduce the swelling. Your vet is likely to also prescribe anti-inflammatories such as phenylbutazone (bute), for both pain relief and to help reduce the swelling.

It is important to inhibit the natural inflammation that occurs with an injury as far as possible during the acute phase as this can force the damaged tendon fibres to separate further, worsening the injury.

Treatment

Once the severity of the injury has been confirmed via the ultrasound scan, your vet will be able to prescribe suitable treatment and a rehabilitation program to follow to slowly bring your horse back into work.

Cases where there is a clear hole (core lesion) showing on the scan may benefit from the injection of either platelet rich plasma (PRP)¹ or stem cells² into the injured area to help kick start the healing process by releasing growth factors into the site of the tissue injury.

PRP is produced from a sample of blood taken from the injured horse. The blood is either passed through a filter (which can be done on the horse’s own stable yard, removing the risk to transporting a horse with an injured tendon to a specialist veterinary clinic) or placed in a centrifuge (if the horse is located at a vet clinic with this equipment), which increases the number of platelets and growth factors the sample contains.

The PRP sample can be ready to inject into the horse within 15-30 minutes after taking the blood sample. The injection site is clipped and cleaned thoroughly to reduce any risk of infection. Then the injections are directed into the site of the injury under the guidance of an ultrasound scanner while the horse is under standing sedation and after having local anaesthetic applied to the area. The leg is then bandaged for 24/48hrs while the horse remains on box rest.

Stem cells are also taken from the injured horse and then cultured in the lab before being injured into the site of the injury, similar to PRP. The bone marrow harvesting process is invasive for the animal, and must take place at a specialist clinic. Once the harvested cells are in the lab, it takes several weeks for them to be cultured and prepared for use.

Recent research has reviewed other forms of regenerative therapy, including using stem cells sourced from embryos. These embryonic stem cells grow forever in the lab so can be ready to use immediately and scientists believe they work by helping to rebuild the tissue directly, reducing the amount of scar tissue laid down.³

There are also surgical options that are more commonly used to repair marginal tears or defects of the deep digital flexor tendons within the digital flexor tendon sheath by tenoscopy. This may be combined with regenerative therapies, such as stem cell or PRP injection.

In all tendon injuries, controlled exercise from the early days is considered beneficial, but turning the horse out is not. Walking the horse in-hand on a firm non-slip surface over gradually increasing periods of time followed by several months of walking under saddle, then ridden walking and trotting would be a normal exercise programme while rehabbing a damaged tendon.

Some horses benefit from light sedation during the walking stages to reduce the likelihood of them suffering a set back for the injury caused by leaping around.

While traditional exercise boots or bandages cannot help support an injured tendon during exercise, there are now orthopaedic boots available⁴ which are designed to stop the fetlock joint from over extending, thereby preventing additional injury to the soft tissue at the rear of the leg during rehab. These boots are only suitable for use during the horse’s recovery and can be hired on a veterinary referral basis.

By monitoring the tendon’s healing process with regular ultrasound examinations your vet will be able to tailor a convalescent work programme for your horse and advise as to when paddock turnout can be introduced.

As a general rule, an injured horse should have an ultrasound examination of the injury before each increase in the level or type of his work.

Most horses should convalesce after a serious tendon injury for between nine and 12 months.

Prognosis after a tendon injury

The prognosis following injury depends primarily on the level of damage and the horse’s job. The tissue that is laid down in the tendon after an injury is never as effective as the original tissue and therefore will always be at risk of reinjury.

Many horses do successfully return to work and competition after tendon injuries after a suitable period of rehabilitation. The owner/rider must decide what level of work/competition is appropriate for the horse following an injury, in conjunction with their vet. In some cases it may be wise to reduce the risk of reinjury by adjusting the level or type of work required from the horse.

References:

1, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015224/ – Effect of intralesional platelet-rich plasma (PRP) treatment on clinical and ultrasonographic parameters in equine naturally occurring superficial digital flexor tendinopathies – a randomized prospective controlled clinical trial – September 2016

2, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582602/ – Strategies of tenogenic differentiation of equine stem cells for tendon repair: current status and challenges – June 2019

3, https://www.horseandhound.co.uk/news/animal-health-trust-embryonic-stem-cell-research-tendon-injuries-682011 – Top scientists make breakthrough in stem cell research for tendon injuries – March 2019

4, https://www.equinetendon.com/equestride/

5, https://www.ncbi.nlm.nih.gov/pubmed/14649360 – Lameness in 46 horses associated with deep digital flexor tendonitis in the digit: diagnosis confirmed with magnetic resonance imaging – November 2003

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Tendon injuries in horses: facts that might surprise you

Professor Roger Smith educates us on tendon injuries and how we look at them...

A novel treatment using extracted bone marrow has given new hope to a sport pony with a ligament injury, as Matt Smith MRCVS explains

The sesamoidean ligaments form part of the suspensory apparatus. Two bones at the back of the fetlock, known as the sesamoid bones, act as an anchor. Above them runs the suspensory ligament, from fetlock to hock/knee, and below them sit the distal sesamoidean ligaments.

The anatomy of the sesamoidean ligaments is complex. There are four ligaments in each leg, with fibres running in different directions and with different attachment points. Together, they act as a relatively tough and elastic “sling” that provides support to the fetlock and pastern region.

Due to their function, most injuries to these ligaments are thought to be caused by over-extension of the fetlock joint. While the specific event may be unknown, this type of acute injury is most likely the result of a one-off bad step or a steep landing over a fence, for example.

Injuries can also occur as a result of chronic repetitive strain, from regular work. Other factors are then relevant, including the horse’s conformation and genetics, the type of work he undertakes and the surface used. Horses with straight hocks and overextended fetlocks appear predisposed.

Since there are rarely any external signs, such as swelling or heat, diagnosis can be difficult. Nerve blocks may be required to localise the source of lameness. One clue is a positive response to a fetlock flexion test, but this is not specific to sesamoidean ligament injuries.

Diagnosis is generally confirmed by ultrasound, although the ligaments can be difficult to image — particularly in thick-skinned, cob-type horses. Magnetic resonance imaging (MRI) may be necessary.

Stimulating repair

Treatment is largely based around a period of rest and controlled exercise, in the form of a graduated walking programme, much like any other tendon or ligament injury. Success rates have typically been poor, however, which has led to the creation of new techniques aimed at stimulating repair.

One such treatment is shockwave therapy. While useful for proximal suspensory desmitis (PSD), the response with sesamoidean ligament injuries has been less positive.

Sport pony Cherryhills Arctic Kiss (known as Callie) had developed a hole in a hind sesamoidean ligament, an injury that does not tend to heal well. Callie had not come right with a few months of rest, so we knew that giving her more time was not the answer.

We decided to treat the injury with a form of stem cell therapy called bone marrow aspirate concentrate (BMAC). Still relatively untested for sesamoidean ligament injuries, BMAC offers a number of potential therapeutic benefits.

Unlike the more widely known stem cell treatments, where the cells are sent to a laboratory to be “cultured” to produce many millions more, those in BMAC remain unmanipulated. Not only can the bone marrow be aspirated (extracted) from the horse and administered back into the injury site shortly afterwards, but it is thought that the unmanipulated cells retain more of their potential therapeutic qualities.

The horse is given local anaesthetic so the bone marrow can be extracted from his sternum using a large needle. The aspirate is then placed in a centrifuge for 15 minutes. This concentrates the stem cells and growth factors naturally found in the marrow. It also filters out white cells and other tiny particles known as bone spicules.

The sample is then ready to be injected into the injured tissue. This is performed under ultrasound guidance and either standing sedation or general anaesthesia, depending on the location of the injury. Because the sesamoid ligaments are difficult to access and situated close to structures such as the tendon sheath, Callie was anaesthetised for the whole procedure.

What’s the prognosis?

Previously, it was suggested that stem cells regenerated injured tissue by forming new tendon, ligament or cartilage. We know now that they orchestrate healing by exerting a “paracrine effect”, secreting factors that signal the horse’s own cells to change their behaviour.

Whereas we would once inject as many stem cells as possible, the aim of BMAC is to guide healing of cells already there. In addition, the growth factors from the bone marrow combine to stimulate better-quality repair than the proliferation of new tendon or ligament fibres generated by the regenerative therapy platelet rich plasma (PRP).

The prognosis for sesamoidean ligament injuries remains guarded, however, and will relate to the cause — greater success is seen with acute rather than chronic injuries. A treatment such as BMAC is generally more effective the sooner it is given after the injury.

Most tendon and ligament injuries will heal, in a fashion, but the question is whether the repair will stand up to work. Follow-up scans revealed Callie’s injury had filled in significantly, so she was able to undergo a careful rehab programme and resume exercise.

Stem cell therapies are a tool we can reach for with tendon and ligament injuries in an attempt to bring about a good outcome. While refinements will no doubt be made to these techniques, they are a step forward in the treatment of these often challenging injuries.

The owner’s view

Hannah Freer describes the onset of Callie’s sesamoidean ligament injury in late 2017 as “insidious”.

“She has always had plenty of power, but when I was schooling her she felt sluggish — as if there was no engine,” says Hannah of the 14hh home-bred mare, now 11. “My vet looked at her and couldn’t see any mechanical lameness, but I felt that Callie wasn’t quite right.

“After a few weeks’ box rest, some new gait analysis software at the clinic revealed she was lame on her left hind,” continues Hannah, an accident and emergency nurse. “She seemed to react positively to a proximal suspensory nerve block and underwent a course of shock-wave therapy, but things still didn’t seem right.

“In January 2018, I took Callie to see Matt Smith at the Newmarket Equine Hospital. He went over her with a fine-tooth comb and finally discovered a hole in a sesamoidean ligament. It was awful news. Matt explained the injury probably hadn’t been caused by one incident, rather a combination of things.

“We discussed treatment options. An injection of steroids into the hole might just trigger a healing action, while PRP treatment offered a 50/50 chance of success. We felt that BMAC, while more expensive and relatively untried, was our best bet.

“Callie was in hospital for a couple of days for the treatment. Back home, my dad and I followed the rehab programme to the letter. We were out walking her around the arena that winter in wind, rain, snow and hail, not finishing a session until the timer went ‘beep’. I was back on her in March, hacking her in straight lines, before moving on to gentle hillwork. By June, she could start cantering.

“I haven’t really jumped Callie yet, as I’m frightened of undoing all the work, but this year she earned her first British Dressage points and qualified for the Area Festivals in four outings. I was so lucky to get my horse back.”

Matt Smith MRCVS is a surgeon and partner at Newmarket Equine Hospital. This purpose-built referral hospital is one of the largest in Europe, treating horses from throughout the UK ranging from leisure animals to elite athletes. Matt is a Royal College of Veterinary Surgeons (RCVS) specialist in equine surgery and has a particular interest in orthopaedic problems.

Ref Horse & Hound; 24 October 2019

A tendon injury is a devastating blow for horse owners. Professor Roger Smith, European and RCVS recognised specialist in equine surgery at the Royal Veterinary College, says that tendons can be injured in two ways. Firstly they can become damaged through external trauma such as a blow or a laceration and secondly and most commonly, as a result of over-loading.

But as we begin to understand more about the causes and consequences of tendon injury, should also become more discerning about the treatments we employ?

Here are few facts about treating tendon traumas that may surprise you:

1. Long periods of box rest aren’t appropriate.

“There is a gold standard of treatment for tendon and ligament injuries,” says Roger. “We believe managing tendon injuries with long periods of complete box-rest or ‘field rest’ is not appropriate.”

Below are the suggested time guidelines for a rehabilitation programme for common tendon and ligament injuries. (These time-lines should only be used as a guide and can be modified depending on clinical progress, as judged by your veterinarian and with the use of ultrasound).

2. New treatments should be approached with care

“The main limitation for a vet is knowing whether these new treatments will actually work,” continues Roger. “This requires data from clinical cases which can be hard to collect in meaningful numbers. As an illustration of this, a statistical calculation (known as a ‘power calculation’) was made a few years ago to estimate the numbers of horses that would have to be treated using a new treatment to show a significant improvement in outcome for superficial digital flexor tendinitis of a 50% reduction in re-injury rate, and this was 88 horses per group (see ‘Consensus on equine tendon disease: building on the 2007 Havemeyer symposium’ [1]). Consequently, few tendon treatments offer the same kind of confidence that we expect from most human treatments. With new treatments, this will inevitably be limited and so should be approached with caution — we should not be using treatments with no evidence base, especially if it causes harm (or pain) to the horse.”

3. Firing tendons is ineffective

Roger also says that ‘well-established’ treatments which do not show positive effects should be abandoned:

“A good example of this is the firing of tendon injuries, where large studies have shown it to be ineffective and no studies show positive results even after many years of use, and for which significant welfare issues exist for many. Therefore, adoption of new (and established) treatments for a tendon injury should require careful consideration relating to the principles outlined above, the evidence for its use, and, most importantly, discussion with your veterinarian who is best placed to help you decide whether it is appropriate or not.”

4. Sudden bouts of exercise can bring out an underlying injury

Roger says the most common injuries affecting the superficial digital flexor tendon and suspensory ligament are thought to arise through accumulated microdamage.

“While cyclical loading is important for a healthy tendon and drives the development of a strong and resilient tendon in the young growing animal, it results in accumulated microdamage in the adult (post 2-3 years of age), similar to repetitive strain injury, which weakens the tendon so that a bout of intense exercise when ridden or in the field can result in an apparently sudden injury.”

Article continues below…

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5. Prevention or cure?

“Research continues to identify key mechanisms behind early subclinical ‘degenerative’ phase which actually offers an opportunity to intervene as a preventative approach,” says Roger. “Two possible preventative approaches stem from this understanding – (i) improving the tendons resilience to injury during its competitive life-span by enhancing its development. This is most likely to be achieved by optimising ‘conditioning methods’ for young stock (figure 2); and (ii) slowing or stopping the degenerative process in the adult.”

An example of this is the work currently being done on developing methods that counteract the process of cellular ‘ageing’, thought to be behind many age-related degenerative diseases in humans.

For all the latest equestrian news and reports, don’t miss Horse & Hound magazine, out every Thursday. Don’t miss this week’s vet special (18 April) to read the full feature on tendon injuries, and how new research is changing the way we treat them.

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A new form of stem cell treatment could give horses a better chance of recovering from tendon injuries, researchers have suggested.

Stem cell researchers at the Animal Health Trust (AHT) have found positive signs that stem cells originally sourced from embryos coped well in laboratory tests when exposed to inflammation. This is important as inflammation that occurs following an injury can prove damaging to adult tendon cells.

Tendon injuries are a common problem in horses and instead of regenerating healthy tendon tissue, they repair by forming scar tissue which pre-disposes the horse to a high risk of re-injury.

Stem cell treatment has been available for some years, but current treatments use the horse’s own stem cells.

This means they are not available for immediate use as they need to be extracted, cultured and separated from other cells, with the overall timeframe taking several weeks.

Current treatments also work by releasing factors to help tissue repair, rather than rebuilding the tissue itself.

However the embryonic stem cells grow forever in the lab so can be ready immediately and scientists also believe they work by helping to rebuild the tissue directly, reducing the amount of scar tissue laid down.

The recent work has been funded by the Horserace Betting Levy Board, Racing Foundation, Alice Noakes Memorial Charitable Trust and Beryl Evetts and Robert Lugg Animal Welfare Trust.

Using a laboratory model they found that adult tendon cells cannot produce “artificial” tendons efficiently when exposed to inflammation.

In contrast, they found that embryonic stem cells that were directed to turn into tendon cells behaved as normal when exposed to inflammation.

Dr Debbie Guest, head of stem cell research at the AHT said: “We were able to demonstrate that these tendon cells express different levels of receptors for inflammatory proteins on their surface.

“This means that these stem cells may provide a useful source of cells for clinical transplantation into the injured tendon as they are unlikely to suffer any negative effects from being placed into an inflamed environment.”

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A spokesman for the AHT said the team believes this opens up the possibility of further studies to understand more about how embryonic stem cell-derived tendon cells protect themselves from inflammation, with a view to developing new treatments that could be used to protect adult tendon cells following injury.

“Protecting tendon cells from inflammation could help to improve the regeneration of healthy tendon tissue to reduce the risk of re-injury and allow more horses to remain in active work,” added the spokesman.

“Funding for a follow up study by the Animal Health Trust, in collaboration with the Royal Veterinary College, has been secured from the Horserace Betting Levy Board and the team are hopeful that new treatment options for this old problem may soon be developed.”

For all the latest news analysis, competition reports, interviews, features and much more, don’t miss Horse & Hound magazine, on sale every Thursday

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With the emergence of advanced imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) in veterinary medicine, our understanding of the internal construction of the foot has improved greatly. We are no longer restricted to using the generic term “navicular disease” as a diagnosis based on radiographs (X-rays), but instead can see the plethora of structures within the hoof capsule, referred to as the podotrochlear apparatus.

The podotrochlear apparatus comprises various joints, bones and tendons, as well as key ligaments: the collateral ligaments of the distal interphalangeal joint (sometimes called the coffin joint), the distal sesamoidean impar ligament and the collateral sesamoidean ligaments.

While tendons and ligaments are similar in structure, with both being made up predominantly of bundles of type one collagen strands, or “fibrils”, they differ in that tendons attach muscle to bone and ligaments attach bone to bone. This has an effect on function, in that tendons serve to move a bone or joint, whereas ligaments serve to hold structures together and keep them stable.

Casing the joint

How do the foot ligaments operate — and what can cause them to fail?

The collateral ligaments of the distal interphalangeal joint are paired, with one on the lateral (outside) and a second on the medial (inside) aspect of the joint.

They originate on the middle bone segment, or phalanx, and run obliquely to insert on the distal phalanx (distal meaning furthest from the body).

The role of these ligaments is to provide stability to the joint, so they can become damaged if the joint slides or rotates. The ligaments can also degenerate with age — small, repetitive stresses may culminate in damage, as well as a single, large injury.

Damage to the collateral ligaments will cause a variable degree of lameness, usually in one or both forelimbs, which worsens when the horse is turned or lunged. Sometimes, there may be swelling above the coronary band. In most cases, the ligament will be damaged more distally, within the hoof capsule, so there will be no abnormalities on clinical examination. Joint instability will be evident only where the ligament is severely damaged.

Diagnosis is made after localising the lameness to the foot using a nerve block. Some more proximal lesions (those nearer to the body) may be identified on ultrasound, and occasionally a bony reaction at the ligament’s origin or insertion will be evident on X-rays. Usually, MRI or CT is required to identify collateral ligament injury accurately.

Rest is central to rehabilitation, with a minimum of two months’ box rest followed by four months’ walking in straight lines — perhaps on a water treadmill.

Other treatment options in cases with a suitable and accessible core lesion include injection of the ligament with platelet-rich plasma (PRP) or mesenchymal stem cells.

Where there is associated synovitis (inflammation of the membrane surrounding a joint) or osteoarthritis of the distal interphalangeal joint, medication of the joint with corticosteroids, hyaluronic acid or a natural anti-inflammatory called interleukin receptor antagonist protein (IRAP) can be considered.

Farriery is important in the management of these cases, with strict attention being paid to the mediolateral (side-to-side) balance of the foot. Some farriers will choose a wider shoe branch on the injured side in such cases; others prefer leverage-reduction shoes designed to relieve pressure on these structures.

Chronic changes

The most common issue with the distal sesamoidean impar ligament is chronic degenerative change as a result of ageing, often in conjunction with damage to the navicular bone, navicular bursa and deep digital flexor tendon.

Damage to the impar ligament is best investigated using the superior quality of high-field MRI. Because the ligament is quite flat, it is difficult to image on low-field (standing) MRI and may be missed on thicker CT image “slices”. Even so, standing MRI can identify damage to the bone at the insertion of the ligament, allowing diagnosis of impar ligament injury.

Ultrasound of the impar ligament through the frog is possible, although recent research has shown a wide variation in the ultrasound appearance of the ligament in sound horses. A portion of the ligament can also be seen on arthroscopy (keyhole investigation) of the navicular bursa.

Distal border fragments of the navicular bone may also be evident in association with impar ligament injury, but the clinical significance of these needs to be interpreted with caution, as this can also be found as an incidental finding in sound horses.

As with the impar ligament, injury to the collateral sesamoidean ligaments rarely occurs in isolation. Damage may be suspected when X-rays reveal new bone formation around the navicular bone at the ligament’s insertion. As this may also be found in sound horses, MRI or CT imaging is required for accurate identification.

Rest and rehab

Treatment of chronic impar and collateral sesamoidean ligament injury is similar and will depend on the degree of concurrent damage to other structures of the hoof capsule. Generally, rest is advised, except where the degenerative change to the navicular bone or distal interphalangeal joint is the primary problem, in which case a compromise must be reached.

Commonly used medications include anti-inflammatories such as phenylbutazone (bute) and bisphosphonates such as tiludronate or clodronate.

Good farriery is key, with attention being paid to foot balance. Different farriers have achieved successful results with a variety of shoes, such as natural balance, egg-bar, heart-bar and straight-bar. Elevating the heel can help to relieve pressure from the deep digital flexor tendon on the palmar (rear) aspect of the navicular bone.

Other treatment options such as shockwave therapy and the introduction of mesenchymal stem cells have been used, but scientific evidence to support their effectiveness is lacking.

Rarely, acute injury to the impar ligament, thought to be caused by trauma, has been reported. Both arthroscopy of the navicular bursa and conservative management have been tried, but the scarcity of such cases makes it impossible to give exact treatment recommendations.

Case study

A nine-year-old Irish Sport Horse mare came to us at the Bell Equine veterinary clinic for MRI examination. She had moderate left forelimb lameness when lunged on the right rein, which had first become apparent nine months previously. This lameness disappeared with a palmar digital nerve block.

Radiography of the mare’s feet revealed no abnormalities. When she was rested, she became sound, but the lameness reappeared when she returned to work. Again, a palmar digital nerve block located the lameness in her foot.

The MRI images revealed damage to the distal sesamoidean ligament, with a large cystic lesion in the distal phalanx at the insertion of the ligament (indicated by arrows). The mare is being rested, as treatment is limited when the damage is located so deep within the foot.

Ref Horse & Hound; 19 July 2018

A competition horse has bounced back from a serious tendon injury picked up as a result of a fall out hunting to win on his eventing comeback after 18-months off.

The 17hh gelding, Artic Skippy, quickly moved up the levels to two-star during his first season with owner Emma Hawksby. The 28-year-old County Durham-based rider bought the chestnut in February 2016 as a eight-year-old.

The family subscribe to the Zetland Hunt and Emma’s mother Angela took Skippy out on 8 December after she heard H&H were covering the day.

“The only reason she went on Skippy that day was because H&H were with us and she didn’t want to go out on a youngster,” recalls Emma, who has 20 horses in her yard, producing them for owners.

“They were just cantering across a field with long grass and Skippy put his front legs down an unseen drain. He flipped over and my mother broke her neck,” she told H&H.

Angela was taken to the James Cook hospital in Middlesbrough where scans showed she’d broken C4 and C6 bones in her neck.

Doctors said there was no need for an operation and she could leave the hospital that day providing she was careful and wore a neck brace.

Skippy’s prognosis for a full recovery was not so good.

“He’d put a gigantic hole is his SDFT (superficial digital flexor tendon) and was very lame,” said Emma.

Vets at Hambleton Equine Clinic, Stokesley, where he’d gone for treatment suggested trying stem cell treatment and took cells from bone marrow in his sternum.

These were sent off and three weeks later the harvested cells were put into two locations in Skippy’s leg.

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The horse then had four months box rest at home before going to a local yard to go on a walker for six weeks, then coming home for six months field rest.

Even after further laser treatment, vets weren’t optimistic about his chance of competing again.

“Vets said he had a 50:50 chance of making a full recovery,” said Emma.

“I would have been happy if he’d been able to have some form of a lifestyle, perhaps as a hunter, but never thought he would come back to event properly again.”

Last December he was walked for eight weeks, then trotted for another eight weeks before starting canter work.

Emma didn’t jump Skippy until May, but later that month at the Northumberland County show (27 May) he finished second in the open working hunter class.

She then entered him nervously for the novice Aske International Horse Trials on 30 June, where to her delight he won a novice section.

“I only wanted him to come home safely and never expected him to win,” she said.

The pair’s next outing is on 27 July in the CIC 2* at Burgham Horse Trials.

In this week’s Horse & Hound magazine, out on Thursday 12 July 2018, don’t miss our ‘Rider fitness’ special including what top riders eat, fitness for across the disciplines and more.

Plus, read our interview with Royal Ascot-winning trainer Eve Johnson Houghton and in this week’s ‘Vet clinic’ we take a look at bacterial meningitis in horses. We also have reports from eventing action at Barbury, racing from Sandown Park and much more.

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Rick Farr of Farr & Pursey Equine Vets shares his expert advice on check ligament injuries and how to best treat them

Q: Check ligament injuries: “My dressage horse was diagnosed with a check ligament injury four weeks ago when I found a swelling on his leg. He has never been lame on it and is not lame now. My vet scanned it four weeks ago and advised two months box rest with the first two weeks completely confined to his stable with no walking out. Then after this two weeks he said to start walking him out either in hand or under saddle beginning at 10 minutes a day building up each week until we are road walking for an hour and a half. After this we would then start to look at trotting.

“My horse was doing well and his leg had gone down a lot, then yesterday morning when I took off the bandage it was swollen again. He still isn’t lame however. I’ve decided to get the vet back tomorrow and not walk him over the weekend.

“I’ve had so many different treatments suggested, some say total box rest for six weeks, some say turn away — what is your advice on treatment and what is the prognosis for such injuries?”

A: From your description I presume you are talking about a forelimb and, most likely, the ‘accessory ligament of the deep digital flexor tendon’ (ALDDFT). This is a short ligament located just below the knee and is a direct continuation of the palmar carpal ligament, which joins/merges into the deep digital flexor tendon (DDFT) in the middle cannon bone. Its main role is to provide stability as the knee fully extends and, in the mid-stance phase of the stride, also shares the tensile load of the limb with the DDFT.

Continued below…

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So why and how does this ligament get damaged? I usually describe the ALDDFT as a ‘fail safe’ for the DDFT. When the DDFT comes under excessive load as the knee and fetlock fully extend something has to ‘give’. This is usually the ALDDFT — which is better than rupturing the DDFT! The extent of damage always varies, however the damage and subsequent lameness is usually sudden in onset and is commonly associated with localised soft tissue swelling just below the knee on the back of the limb.

Ultrasound is the mainstay of attaining a definitive diagnosis and it is important that the ALDDFT is compared in both limbs and equally the DDFT and Superficial Digital Flexor Tendon (SDFT) are also checked as concurrent damage to surrounding soft tissue is equally as common, especially when associated with profound lameness.

It is common to see and feel persistent thickening to the area surrounding the ALDDFT post-injury and, as you have already pointed out, this is not always associated with lameness.

Historically we used to rest all tendon and ligament injuries, however we are starting to appreciate that specific controlled exercise is crucial in any convalescent period. Given enough of a chance (especially when damage is more profound) adhesion formation to the ALDDFT’s surrounding soft tissues is common. This will result in mild lameness during early exercise phases. However, it is important to note that with controlled exercise and monitoring progress with ultrasound it is possible to get many horses back into full work.

At our practice we advise horses are re-scanned around 4-6 weeks after the initial diagnosis and follow-up scans are repeated every 4-6 weeks if lameness persists. Occasionally, if adhesions are noted, localised injection of substances such as sodium hyaluronate can help to reduce their formation. Correction of any foot imbalances is also imperative.

As a general ‘rule of thumb’ clinical improvement usually precedes what is deemed normal on an ultrasound scan. Clinically we tend to find most horses are completely sound within 3-9 months.

The prognosis for returning to full athletic performance in an uncomplicated case of damage to the ALDDFT is good.

I have included our ‘generalised’ exercise plan which we give to patients with uncomplicated cases — having most horses back into work within three months, which you can see above. I should emphasise that every case is different and should be managed on its own individual merits. Careful discussion with your vet post ultrasound, in conjunction with your own horse’s tolerances to controlled exercise, should always be made.

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The horse’s limbs have evolved as bony columns with palmarly (back of the leg) situated tendons that act as springs to store energy from each stride. As a result the horse has very long flexor tendons, of which there are two — the superficial digital flexor tendon, which has most of the spring-like function, and the deep digital flexor tendon, which serves more of a positional and supportive role for the foot (see diagram, below).

The deep digital flexor tendon (DDFT) is in excess of 50cm in length in the adult horse, attaching to muscle above the carpus (knee) in the forelimb and the hock in the hindlimb. It runs down the back of the leg, beneath the superficial digital flexor tendon, around the fetlock and inserts into the back of the coffin bone inside the hoof.

Where it changes direction around a number of joints that flex and extend, the tendon is under compression and is surrounded by structures known as tendon sheaths or bursae. These contain synovial fluid, ensuring that movement is almost frictionless. Tendon tissue in these regions resembles cartilage, containing significantly greater amounts of pressure-resisting proteins with fewer blood vessels.

These adaptations result in limitations to the normal healing mechanisms and so make treating injuries of this structure challenging.

Damage and degeneration

Spontaneous overstrain injuries to the DDFT are rare in the proximal limb (near the attachment) and most frequently occur within one of the regions enclosed by a tendon sheath or bursa.

The reason for this is unclear, but injuries are more common where the tendon is under compression from a bony prominence. Damage is thought to be degenerative and the tendon often contains areas of mineralisation as a result.

Injuries can affect the internal parts of the tendon (core lesions or mid-substance tears), the outer surface of the tendon (border lesions or tears), or the insertion site of the tendon on the coffin bone.

In some cases, although usually only those where there has been damage to the adjacent sheath wall, adhesions can also form, which can limit tendon movement and cause pain. Paradoxically, this can improve healing of the tendon itself, as adhesion can supply cells and vasculature to the lesion and seal it from the synovial environment.

Most DDFT injuries affect the forelimb and cause lameness, which is usually variable, unilateral and persistent. Traumatic injuries are also quite common and usually occur in the pastern region where the back of the leg comes close to the ground when bearing full weight at speed. When the DDFT is either completely severed by an external injury, or spontaneously ruptures, the characteristic sign is the toe coming off the ground when the horse bears weight on the limb and can result in partial dislocation of the coffin joint.

What to look for?

External clinical signs can vary, but the obvious clue is swelling.

A lesion within the confines of the digital sheath usually causes sheath distension, resulting in asymmetric windgalls. The degree of distension varies but is usually more marked where the injury involves the border of the tendon and is in contact with the synovial environment.

Lesions within the hoof show few external signs, although careful palpation of the two lobes of the DDFT between the bulbs of the heel can sometimes reveal pain. The horse may rest the limb when in a stable by “pointing” (placing one hoof in front of the other).

These clinical signs are far from specific, so localising lameness using nerve, joint, tendon sheath or navicular bursal “blocks” is crucial.

For injuries within the digital sheath, instilling local anaesthetic into the sheath will usually resolve lameness. This can be combined with radiographic contrast to give useful diagnostic information on the presence of a tear and the tightness of the annular ligament at the level of the fetlock.

Ultrasonography is effective in the digital sheath area, where mid-substance core lesions can be easily visualised. Border tears have been more challenging, however, although modifications to the examination procedure can improve the frequency of identifying them.

MRI has proved the most useful imaging technique for revealing lesions within the hoof, once lameness has been localised.

Which treatment is best?

As with most soft tissue injuries, the mainstay of treatment for DDFT injuries is rest and rehabilitation. Long periods of rehabilitation are necessary, often of up to a year, consisting of rest followed by a slowly ascending exercise regime.

Corrective trimming and shoeing can help lesions within the hoof, where every degree of increase in the downward angulation of the coffin bone results in a 4% reduction in loading of the deep digital flexor tendon and the navicular bone.

Provided there is adequate sole thickness, this can be achieved by trimming the sole at the toe region, preserving the heels and shortening the toe. Raising the heels with a graduated shoe or plastic wedge inserts can also help, although their long-term use is thought to be associated with heel collapse.

Lesions communicating with the synovial cavity of the tendon sheath or bursa result in inflammation (tenosynovitis or bursitis), and healing is further inhibited by the synovial fluid.

Hyaluronic acid, a key component of the lubricating properties of synovial fluid, can be injected into the tendon sheath or bursa in an attempt to limit adhesion formation. Inflammatory tendon sheaths and bursae are frequently treated with corticosteroids, although their use can delay or halt healing and should be avoided when a healing tendon injury is identified.

Injury to the external border of the tendon can result in the prolapse of damaged tendon fibres into the tendon sheath or bursa. These can remain in the synovial environment, causing inflammation and lameness. Minimally invasive surgical debridement (removal) of these fibres may be justified, using tenoscopy or bursoscopy. The lesion still needs to heal, however, which does not always occur.

Contained lesions may benefit from intra-lesional treatment with mesenchymal stem cells or platelet-rich plasma (PRP). Success rates for these treatments in DDFT injuries are largely unproven, although data for the treatment of superficial digital flexor tendon injuries with stem cells show significant benefit. At present, injecting stem cells or PRP solely into the tendon sheath does not appear to improve outcome.

DDFT injuries are serious and have a high failure rate — evaluation indicates a positive prognosis of 30-50%. Careful choice of treatment and meticulous rehabilitation can enhance the prospect of a return to performance.

Ref: Horse & Hound; 5 May 2016

A breakthrough in tendon research has taken the veterinary world a step closer to better understanding injuries.

Researchers from Queen Mary University of London and the University of Liverpool have found why tendons in older horses may be more prone to injury.

They took samples from different parts of the forelimb superficial digital flexor tendon from groups of four young horses and four older horses while conducting the study last year.

The equines used were half- to full- thoroughbreds and all had been put down for reasons other than a musculoskeletal injury.

The young horses were aged between three and six years old, and the horses in the older group were between 17 and 20 years old.

Using a state-of-the-art profiling technique, the researchers identified which proteins were present in different parts of the tendon.

They discovered the specific proteins that help the tendon fibres to slide past each other, and found that these are replaced less quickly as a horse ages.

All tendons are made of subunits containing rope-like collagen surrounded by a material called the interfascicular matrix (IFM), which binds them together.

Co-author Dr Chavaunne Thorpe said they looked at the IFM — a soft and extendible material which allows the subunits to slide past each other and the whole tendon to stretch.

“We now know that the increased stiffness of the IFM with ageing is probably due to the reduction in the renewal of proteins in this region, which allows damage to accumulate,” she told H&H.

This information will now allow scientists to develop treatments for tendon injuries, which specifically target the IFM.

The study was published in the Scientific Reports journal today (4 February) and was funded by the Biotechnology and Biological Sciences Research Council.

“When a horse moves, its muscles generate a massive amount of energy that is stored and released by the tendons in their legs,” Dr Thorpe added.

“The key to the effectiveness of tendons is the ability of the fibres that they are made up of to slide across each other.

“When this ability to slide is reduced, the energy damages the tendon instead of being stored and released by it.”

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The words “tendon injury” fill most horse owners with dread. But even with a poor initial prognosis for tendon injuries in horses, there can be a happy ending, as show horse Pink Floyd proves.

The successful large hack qualified for Horse of the Year Show two years ago — during his first season competing in the show ring — and his owner, Sarah Briggs, envisaged an exciting career ahead. But less than a week after returning from Birmingham, the 16hh gelding severed a tendon and his future looked bleak.

“He was only six and had his whole life in front of him,” says Sarah, who bought the half-brother of multi-titled Pearly King as an unbroken three-year-old.

A son of Kilvington Scoundrel, in 2013 Floyd progressed from novice to open large hack classes with Loraine Homer in the saddle. The pair claimed five championship titles and stood reserves on two occasions.

“No one saw Floyd injure himself because he was in the field. He might have been playing around, and caught himself with a hind leg. Suddenly the girls on the yard saw that he was on three legs and called me.”

The tendon injury

The wound on Floyd’s front tendon was “a good inch deep — he had severed most of the tendon. His fetlock dropped and we had to prop him up to help take some of his weight. Floyd was in so much pain — it was horrible.”

A vet from nearby Hook Norton Veterinary Group treated the wound and applied a heavy-duty bandage. Putting the leg in plaster was also attempted to give the tendon greater stability.

“The vet said straight away that Floyd’s showing career was over because the leg would never look the same. We couldn’t even be sure he would be ridden again — survival depended on the tendon healing well enough for Floyd to live a comfortable life,” adds Sarah.

Tendon injury treatment

The first few days are critical following a tendon injury. Pedantic care, veterinary attention and the horse being a good patient are vital.

“Floyd had good days and I began to hope, but also bad days where he looked uncomfortable. Scans confirmed it was a severe injury, but I wanted to give him a chance.”

Floyd spent six months at Radway Equine Rehabilitation Centre, which is run by Fiona Elliott, a vet at the Hook Norton practice.

Spa treatments became key to the horse’s recovery.

“Floyd didn’t even like stepping in puddles, so at first he was sedated. But by the end he was so relaxed that he would doze in the spa,” recalls Sarah.

Half way through his rehabilitation Floyd was able to walk in slow, straight lines, progressing to large circles and, as the walking increased, spa time decreased.

The next stage

At the end of his six-month box rest, Floyd’s progress was favourable. He returned home and started light, in-hand exercise in a round pen.

In May 2014 he was turned out for the first time.

“He spent six weeks walking first to build up strength, and he was sedated in the field to begin with,” says Sarah. “Turnout came with risks, as fooling around could have undone everything. But he had been in so long that the health benefits — particularly for his mind — far outweighed them and he spent the whole summer outside.”

In October, Floyd moved to Ryan Hawkins’ Swindon yard to return to ridden work.

“Floyd had lost so much strength after a year off, but Ryan did a great job of building him back up. At best I thought he might go hacking, but when his confidence returned on the leg Ryan felt he would do well in dressage.”

Floyd entered a dressage arena for the first time three months later and is currently competing at prelim and novice level.

“It’s a case of so far so good. Floyd wears magnetic boots in the stable just in case, but to date his leg is not causing any problems. It’s unsightly for a show horse, but Floyd makes up for it with expressive movement,” concludes Sarah. “I am so proud of him. He’s proof that tendon injuries aren’t the end of the world and show horses are versatile.”

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When Armageddon struck a tendon while point-to-pointing, his owners feared the worst. But an unusual love of being indoors and a strict management programme boosted his chances and, against the odds, he returned to ridden work. Aimi Clark documents her horse’s extraordinary recovery

Sunday 30 May 2010

Armageddon (“Arnie”), the first point-to-pointer owned and trained by my family, is being bathed and plaited ready for the men’s open at tomorrow’s South Tetcott Hunt point-to-point. This is no easy task; he fidgets and kicks out because he hates fuss. We bought Arnie from Ascot Sales in March 2008, and tomorrow will be his last race before retiring to the hunting field. He is 12 now, and we have had a lot of fun with him.

Monday 31 May 2010

Everyone on the yard is excited; this is our local point-to-point and my family is involved with its organisation, so to have a horse running there is particularly special. Arnie knows it’s raceday; it takes three of us to get his travel boots on and he charges up the ramp. We have learnt to be ready to drive straight out of the yard in order to stop him kicking at the sides.

It takes 20 minutes to drive to Upcott Cross and the venue is buzzing. As soon as I park, banging starts in the back of the lorry. We have timed it so that we don’t have too much waiting to do and Arnie is off the lorry by the time his jockey, Mike Heard, comes to saddle up. Despite all the fidgeting and kicking, once I lead Arnie to the paddock he is as quiet as a mouse — he just likes to get on with the job. There are four horses in the race and at 17.2hh Arnie is the tallest. The going is good and we are hopeful of a solid race. When the jockeys appear, Mike is given a leg-up and follows the rest down to the start. As I let him go, I give Arnie a pat and wish them both good luck.

Disaster strikes

We never pile pressure on our horse to win. Instructions are to listen to him and have a good race, something Mike always does. The field sets off at a decent pace and Arnie is galloping and jumping confidently. It’s not easy watching for my family — we love this horse and that makes us nervous spectators — but it is exciting. It’s a close race and two laps down, Arnie is right up there with the leader. However, our worst fears are realised early in the final lap when, at the fence right in front of us, Arnie takes a funny step in front of it and lands on three legs.

Immediately Mike pulls up. We run to him and see that Arnie’s left-fore fetlock is touching the ground. It’s a horrible sight. Adrenaline is still pumping and Arnie doesn’t want to stand still, so we lead him to the lorry.

Our vet, David Rowlands from Penbode Equine, was by the fence and saw it happen. He meets us at the lorry. Various friends are called on to get ice from the bar; another fetches extra water. David removes Arnie’s boots — he always races in Dalmar racing boots, which have carbon-fibre strike protection. He says that Arnie struck into himself and has injured his tendon. We won’t know how badly until the swelling has had a chance to subside and a scan can be done in a few days’ time.

For now, David applies ice to the leg to help with the swelling and bruising and straps it up to support the tendon while he travels home. It resembles the cast that people wear when they break a leg. Arnie has calmed and the pain is starting to kick in. He is given intravenous painkillers and we have strict instructions to give him medicine in his feed this evening, too.

When we get home we start icing the leg every 20 minutes. We keep the other front leg bandaged too. During the afternoon and night we take it in turns to do Arnie’s leg. There is a risk of colic due to the stress.

Tuesday 1 June 2010

I have never been in this position before. Arnie is at peak fitness but unable to leave his stable. Last night we discussed whether we should have him put to sleep. David has made it clear that Arnie might not recover, and he is unlikely to ever be ridden again. We decide to wait and see what the scan tells us.

Arnie is still relaxed this morning and he has eaten and drunk as normal, even with medicine in his feed. But in the afternoon we hear a commotion in his stable — he is colicking and kicking out with his injured leg. David comes straight out and does a full examination. He determines that leg pain is the cause, and warns us that Arnie might keep doing this. We check him throughout the night and, thankfully, the medication works.

Wednesday 2 June 2010

Arnie is very quiet this morning and lying down. He needs to have an injection every day to help with the pain. As we are a farming family, we are allowed to do this ourselves. However, we can’t give him any in his flanks because he kicks out, so we alternate which side of his neck we put the needle in.

Friday 4 June 2010

Arnie is tolerating his box rest remarkably well. He has a new window in the back of his stable so now he has two views, which he seems to like. He lies down a lot, which is unusual and means his leg is hurting. He gets upset when others go hacking without him, but some chaff keeps him occupied.

David visits to scan Arnie’s leg and confirms that he has severed the tendon, and it is hanging together by a few strands. We conclude that the only reason Arnie stayed on his feet was because the boots softened the blow. Now it’s crunch time.

David explains that a lot of horses would be put to sleep with this injury, but if Arnie is a good patient and can cope with six months’ box rest, he has got a chance of recovering well enough to live a comfortable life. Our hearts rule our heads and we decide to give him a chance. We own horses with whom we wouldn’t attempt this, because box rest would drive them crazy, but we believe that Arnie’s love of being indoors could be his trump card.

The rest of June

David and his colleague Gemma Hearn visit regularly, and we suffer two setbacks. The first is a sore on the healthy leg, which we have bandaged to support it while it bears the majority of Arnie’s weight. He is a big 17.2hh thoroughbred, and we’re aware that his size and weight could work against him. Now we have no choice but to leave the healthy leg unbandaged.

The second setback occurs when Gemma visits to give Arnie an injection. He becomes uncomfortable and colicky, kicking at his bed with his injured leg. Gemma stays on the yard until he settles again, thankfully without more veterinary intervention. The next time Arnie is jabbed we are nervous, but there is no more drama.

July 2010

Because Arnie has not been able to bear weight, his feet haven’t been shod. Worried that this will put unwanted pressure on his tendon, our farrier visits. It’s not a quick process as Arnie can’t stand on his injured leg for long, nor lift the other foreleg very high.

My dad pushes against Arnie’s shoulder so that he can take some of the weight. We also have to be careful with the soles of his feet. Arnie needs a thick bed at all times so that he can lie down if he wants, but this risks thrush. Although his soles do soften, thankfully good management means it never becomes an issue. He wears a flysheet in his stable to stop him kicking at flies and stamping his feet.

August 2010

Three months on and Arnie still hasn’t left his stable. His box in the corner of the yard has a good view of the whole farm, and the second window we added at the back of his stable is doing its job. Every morning Arnie watches the house waiting for us to come out. We can also see into his stable from indoors. My mum isn’t horsey, but she sneaks him a carrot every time she goes out. This makes Arnie happy!

September-October 2010

Arnie is no longer being bandaged during the day, but he is at night. He is moving around his stable comfortably and he has been off his medicine for a while. A second scan shows improvement in the leg, so we begin to hope.

November 2010

David feels the tendon is strong enough for Arnie to leave his stable. We begin by tying him up outside while we muck out and groom. The next step is to let him loose in our yard, which is approximately 15x15m and means he can’t get up any speed. First time out Arnie leaps into the air but, luckily, that’s it. We let him spend as much time as possible loose in the yard.

December 2010- March 2011

We start leading Arnie in-hand around the main yard. We are cautious and he is bandaged, with Dalmar boots on top, and we slowly build up how much he does. His favourite route is going into the garden to graze.

April 2011

With the OK from David we turn Arnie out in a small 20x20m paddock. He leaps and bucks, before he puts his head down to eat. He is never left unattended and after a week of monitored turnout he is allowed into a bigger paddock with one of our veterans for company. For our peace of mind we bandage him each time, and he still prefers to come in at night.

May 2011

Due to mounting vet bills, we have chosen not to have the leg scanned again. Arnie is happy and sound in the field, so he will have the rest of the summer to strengthen. Whenever David or Gemma visits another horse, they assess Arnie’s leg and remark how strong it feels. A white patch has developed on the point he struck into, and the tendon is noticeably bigger than the other. He is wearing shoes in front again to prevent sore feet.

January 2012

Arnie spends the rest of 2011 out of work, but he is sound and happy. He trots and canters around the field confidently, and we start talking about riding him again. We build up to the ride by tacking him up and leading him around the yard for a few days beforehand. After all, it’s nearly two years since he had a saddle on.

Dad volunteers to ride first and Arnie strolls out like he’s never been away. Unsurprisingly he tires quickly and we only do a short loop in walk. Dad starts taking him out on a regular basis, building his fitness slowly until he is walking for an hour. Four weeks in, we box up and take Arnie to a different bridleway. He is very excited and marches ahead of the two fit thoroughbreds my sister and I are riding! It is a great sight.

The rest of 2012

Dad entertains the idea of hunting Arnie again. However, in the end we decide not to risk it. The following year we retire Arnie at the age of 16. He still lives with us today, roaming a large yard at his leisure but still hiding in a stable when it rains. His injured tendon is barely noticeable, and his leg has never given him any problems. We’re very happy we gave Arnie a second chance.

Don’t miss the current issue of Horse & Hound Ask The Vet (Spring 2015), on sale now

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We have a couple of horses in for the rehabilitation of leg injuries at the moment. Often these cases will stay with us for a number of months and we most commonly get them straight from a period of box rest. I have to admit we tend to get rather attached to them when they come in for a long time — they’re like part of the family by the time they leave us.

Both of our current stem cell horses have been treated for superficial digital flexor tendon (SDFT) injuries, but are at different stages in the recovery process. Often the vets will recommend a period of paddock rest in the middle of the horse’s programme, and one of the upshots of ‘phase one’ is to help to in the preparation for this turnout stage.

It sounds crazy to say that you need to prepare a horse for going out in the field, but post-injury you have to be sure that you’ve exposed the leg to enough controlled exercise and allow the healing process to take hold, prior to turning them out.

We seem to get more rehab cases that have been treated with stem cell than cases that have just been rested or treated by other methods. I think there are various reasons for this, but predominantly it seems to be racehorses and either proven competition horses, or those deemed to have a bright future ahead of them, that come to us to begin their return to work.

In our experience, one of the benefits of stem cell therapy is that it cuts down the amount of complete box rest required, with the horses able to start some form of exercise much earlier, albeit in a very controlled environment. Although you’re still pretty much talking about a year away from competition or racing in terms of recovery, evidence and opinion suggest that the chance of re-injury is less than by rest alone, or other traditional methods.

We use the treadmill for rehab cases during their walk and trot work as it allows us to exercise the horse in a very safe and measured way; the surface is wholly consistent, the duration can be dictated to the second, and the speed set to work the horse optimally.

As a result we can just get on with their work, without worrying about them being fresh or jumping around. This in itself is another reason horses are referred to us: the once beautifully-behaved animal can become a fire-breathing dragon, ready to pounce on its owner at the first available opportunity during in hand walking. And who could blame it?

Athletic horses are used to working hard, going out in the field, going off training and travelling to competitions. The treadmill offers a great option for these cases, who benefit from the routine and the need to concentrate on where their feet are landing! Fingers crossed that our current 2 continue to make a full recovery.

All the fun of the fair

I wrote in my last blog that we were preparing for Hartpury’s Summer Fair earlier this month; well, what a great day. We had people from all walks of life through our doors and every one of them was happy for us to show them what we do here.

My boss’ son Max came along to help us with the final preparations for the day, which added an extra level of amusement to proceedings. I was doing the final bit of horse-polishing ready for our last tour at 2.30pm, when he came storming through the treadmill room pointing at his watch. “Fizz, its 2.26! We need you now!” he said. Well, that was me put firmly in my place by an 8-year-old! That boy will go far.

Fizz

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The horse

Ellie, a 16.2hh Irish Sport Horse aged 20 (born 1993), was showjumping up to discovery level with her owner of 8 years, Erica, before her injury. Although she is now fully recovered and can still jump up to 1m, Ellie is now enjoying her senior years as a happy hacker.

The history

In June 2012, during a jumping lesson, Erica noticed that Ellie was not her usual self. A horse who was “usually very forward” was now quiet and “trippy” and although Ellie was not noticeably lame, Erica knew something was awry. She immediately called her insurer, Petplan, who assured Erica that she was covered and could go ahead and call her vet.

Ellie was examined by a local vet who diagnosed suspensory ligament damage to her left-fore. The vet’s immediate advice was to give Ellie bute alongside a few weeks off. This proved unsuccessful, Ellie was still not right, so Erica took her to the same vet for an x-ray.

This showed that although Ellie was only one-tenth lame, her suspensory ligament was torn. The vet was concerned about the likelihood of the mare being able to return to ridden work at all. Erica refused to put Ellie down and instead decided to give her 6 months off over the winter.

Treatment

Following this time-off, Ellie was still lame and, having spoken again with her insurers, Petplan (see below), Erica took her to see Neal Ashton, a soft tissue specialist at Oakham Veterinary Hospital. Neal watched Ellie on the lunge and then used an ultra-sound scan, which showed that there were in fact 2 separate injuries.

The first was tearing of the suspensory ligament close to where it meets the fetlock joint, and the other was a tear to the centre of the superficial digital flexor tendon where it meets the back of the knee joint. Both injuries were long standing and it was clear that they were not healing.

After discussing the options with Erica, Neal went ahead with surgery, putting Ellie under general anaesthetic. Firstly, he identified the suspensory ligament lesion and used keyhole surgery at the fetlock joint. The tear was “open” meaning that loose ligament fibres “float about within the joint fluid” and, therefore, cannot heal.

Neal used suction and cutting to remove the frayed elements and then injected PRP (platelet rich plasma), made in the Oakham Veterinary Hospital’s own laboratory, into the lesion. PRP is a product of the injured horse’s blood, with the growth factors in this blood highly concentrated in order to aid tissue regeneration.

Neal then began keyhole surgery on the second tear, a complicated process as the lesion was in the middle of the tendon rather than on the surface. The tear was also extremely close to the knee joint and the high check ligament. Neal sectioned the latter, releasing its attachment to the back of the knee and therefore relaxing the flexor tendon, giving the knee joint more elasticity. Neal then injected PRP into the lesion.

Neal made it clear that although every horse is different, leaving the injury to heal on its own does not always work, and PRP is a great way of giving the horse’s healing process a “kick up the backside”. The most important point in Neal’s diagnosis is to find out why the wound is not healing and to find an appropriate treatment for this, depending on what the horse’s future use is eg to jump, race, or hack.

After the operation, the Hospital advised Erica to send Ellie to a rehabilitation centre where there would be physio available and a spa. Erica decided against this option as Ellie was visibly distressed at being away from home and had lost weight from the ordeal.

Once Ellie was home, Erica followed Neal’s long and meticulous treatment plan of combining rest with controlled exercise. This began with 8 weeks of box rest. Ellie needed a little sedation at first as her entire leg was bandaged and very restricted movement was necessary.

Ellie was then allowed into a very small sectioned-off area of her field, which Erica moved on to fresh grass every few days. The vet made it clear that every element of Ellie’s treatment must be carried out extremely slowly in order to give her the best chance of recovery.

When Erica came to ride her for the first time, 14 weeks after the operation, she was instructed to go straight to road work, as Ellie’s legs needed resistance rather than soft ground. The roads would “load” and stimulate the ligaments, with Neal suggesting an initial 20-minute walk, building up to 1.5-hour walks, on roads every day for 8 weeks.

Hill work was also added to the routine, with Ellie finding it particularly difficult to go downhill due to the pressure this put on the suspensory ligament.

After eight weeks, Erica could develop this exercise to incorporate 2min of trotting, although still only on roads. After 12 weeks of road work, 26 weeks after the operation, Erica could finally take Ellie on to soft ground and, after a couple of weeks, they went for a gentle canter. A month after they started riding on soft ground, they could jump again.

The food

After Ellie’s operation, Erica knew it was essential to change her food as she was extremely thin, but was also on box rest and had limited means of exercise. Erica rang the Allen & Page advice line so that she could explain her situation and needs fully, rather than trawling through the endless options on suppliers’ websites.

Their expert suggested that Erica begin feeding Allen & Page’s Veteran Vitality, which Ellie immediately loved. It added condition without making her fizzy, and Erica was so pleased with it that she stuck with this feed long term.

The outcome

Erica slowly and steadily built up Ellie’s workload until they were jumping again; with Ellie now back to clearing 1m. The whole process, from injury through to full recovery, took Erica and Ellie just over 14 months.

Erica made the difficult decision to sell Ellie at the end of October 2013. Erica wanted to continue showjumping competitively, and felt that Ellie deserved to retire to a slower pace of life with someone suitable. Ellie now has the perfect lifestyle for her age, as a hack, with Erica only an hour’s drive away.

Because Ellie was 19 when her injury occurred, Erica said that “everyone seemed to write her off” and she felt that most people would have put Ellie down. However, Ellie is proof that horses can recover from this injury, but it does take a great deal of time and patience. Erica is incredibly pleased with Ellie’s full recovery and would encourage others not to give up on a horse with suspensory ligament or tendon damage.

The costs

When a vet advises that treatment is likely to be expensive, the owner is understandably anxious to know whether this will be covered.

Ellie was insured with Petplan and Erica contacted them at the first sign that something was amiss with her horse, and remained in touch with them throughout her treatment. Erica was worried about the costs as the injury developed. Petplan suggested that Erica fill out a ‘pro-forma’ before Ellie’s operation.

This is effectively a ‘dummy claim’ which outlines the approximate price of treatment and which Petplan can assess this as they would a formal claim, aiming to respond to the client within 72 hours with their decision.

If Petplan consents to cover the cost of the treatment, this will be guaranteed. An owner can only achieve this certainty of coverage through this official process rather than over the phone, as the insurer is given the time to assess the case fully.

Ellie’s operation cost £3,000, with Petplan paying £5,000 for all the treatment costs.

Contacts:

Vet – Neal Ashton at Oakham Veterinary Hospital – 01572 722647

Petplan – www.petplanequine.co.uk

* Have you survived a similar experience? Tell us about it below

It's early days but a new diagnostic method is causing excitement, says Peter Green MRCVS

When horses have tendon trouble we now expect the vet to “scan” the tendon.

All equine vets have portable ultrasound scanners with which they examine tendons in the legs on a computerised image. Dark patches represent areas where the normal tight fibres of the tendon have been disrupted or torn and replaced by looser areas of bleeding, fluid and weaker tissue.

Ultrasound scans are commonplace. Magnetic resonance imaging (MRI) is less common but increasingly available for diagnosis of tendon trouble where the ultrasound scanner cannot reach — inside the hoof capsule, for instance. But MRI scanners are very expensive and are not portable.

A recent report has investigated a new technique for assessing leg tendons. Elastography is a development of ultrasound scanning in which specialised computer software generates an image based upon the softness or firmness of the tissue being scanned.

Instead of showing a grayscale screen image of the “echo” of the tendon, as ultrasound does, the screen shows a colour image based upon elasticity of the tissue being scanned. Very soft areas are yellow or red, very firm areas are blue or green.

The technique is used in human medicine to distinguish between benign and malignant tumours. Vets at Davis in California have tried it out on horses’ tendons with very encouraging results. The exciting thing is that the equipment is not necessarily massive and hospital-based — it can be portable.

Availability may be some way off, but it looks likely that horse vets of the future will not only be taking ultrasound scans of dodgy tendons but “elastograms” as well.

Picture by W. Rich Redding and Gabriela Seiler

Research and clinical experience have shown that suspensory ligament injuries, particularly in the hindlimbs, are the highest injury risk in horses doing dressage — at all levels.

The exact cause of injury is not totally clear, but it is likely that a number of things contribute.

Dressage-specific paces or movements could be risk factors, as could the type of horse used.

The repetitive nature of dressage training might mean that the influence of these risk factors is exacerbated — just as human athletes specialising in a particular sport are prone to repetitive strain injury.

Factors that increase the strain placed on the suspensory ligaments are generally associated with an increase in fetlock extension or hyperextension (beyond the normal range of motion).

Excessive exposure to these factors is likely to result in ligament overstrain and injury.

Clinical review suggests that conformation could play a part. Injury is more likely to occur if the horse has a straight hock and a dropped fetlock, probably because he is more likely to hyperextend the fetlock during normal locomotion.

Increasingly, we’re selecting dressage horses with extravagant, uphill movement to get higher scores in competition. Desirable as these qualities may be in the arena, they’ve been identified as factors that increase strain placed on the suspensory ligaments.

How can you minimise the risk of injury?

• Take care not to overpush or overproduce paces. This is particularly the case with an extravagant, uphill mover or a young horse with poor core muscle strength
• Build cross-training and core muscle development into the training programme — but avoid overrepetition of exercises when a horse is tired
• Be vigilant for signs of back pain and schedule frequent and correct evaluation of saddle fit
• Never overtrain on an inferior surface or one that the horse is not used to — and be aware of the risk posed by hard, high-traction surfaces
• If a training problem arises, eliminate the possibility that ligament injury is a reason for resistance. Early detection improves chances of recovery
• For subtle injuries, arrange evaluation by a vet experienced with dressage horses who can assess the horse fully

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Research more about tendon and ligament injuries

Symptoms

Diagnosing a displaced superficial digital flexor tendon can be tricky, not least because an unstable tendon will often slip back and forth from its normal position.

The first sign of trouble is that the point of the hock will become swollen, giving an appearance similar to that of a “capped” hock.

Sedation is essential to calm a distressed horse for examination, while rapid pain relief is also usually necessary.

Once a horse is comfortable, however, anti-inflammatories are best avoided, as it is believed that localised soft tissue swelling can be beneficial for stabilising the injury.

Ultrasound scanning is useful to confirm that the tendon is in an abnormal position and effectively assess the severity of the whole injury to the supporting structures of the hock.

Treatment

Further treatment depends on the nature of the injury and the use of the horse.

If the tendon has displaced permanently to the outside, prolonged rest (around six months) will usually resolve the pain, but the horse may still be mechanically unsound.

This may limit his usefulness for dressage, but it should not necessarily stop the horse racing, hunting or jumping.

Where the tendon slips to the inside of the hock – which is less common – the prognosis is more guarded and tends to result in a more severe gait abnormality.

The fact that SDFT displacements are relatively unusual and a number respond well to rest alone means it is difficult for vets to accurately evaluate the success of different surgical techniques.

Various surgical procedures have been tried to restore the position of the SDFT, including using mesh to reattach the tendon to the point of the hock.

This is major surgery requiring a lengthy convalescence with a guarded prognosis for complete return to soundness.

For unstable luxations that slip on and off, surgery is often necessary to stabilise the tendon.

For the full veterinary article on displacing a tendon off the hock, see the current issue of Horse and Hound (17 November 2011)

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Find out more about tendon and ligament injuries

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Research more about tendon and ligament injuries and MRI scans

In recent years the use of magnetic resonance imaging (MRI) has greatly improved our understanding of lameness that arises from problems in the heel region of the foot.

When a lame horse came sound after a nerve block, we used to rely on X-rays to locate the source of the pain. This often led to a diagnosis of navicular.

MRI imaging has shown that a variety of problems may occur in this region, including pathology of the deep digital flexor tendon as it passes over the navicular bone and attaches to the bottom of the pedal bone.

There may be problems with the bone itself, with the ligaments of the bone or with

the ligaments of the coffin joint.

Clinicians at three American universities have pooled their records to see if they can correlate the outcome of such cases with any specific changes detected by X-ray, MRI or ultrasound scan.

They discovered that the single worst indicator for return to previous athletic ability was the presence of an injury to the deep flexor tendon.

Horses with other problems often made a complete recovery, but those with tendon damage within the back of the foot were much less likely to recover.

The use of MRI has therefore not improved the outcome for horses with pain in the heel region, but it has enabled us to make a much more accurate assessment of whether a patient is likely to make it back into work.

Read more about the latest ground-breaking advances in veterinary research on the vet clinic pages in the current issue of Horse & Hound (9 December)

Find more articles on tendon and ligament injuries and MRI scanning

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Tim Stockdale’s ride Fresh Direct Corlato will be flown home from Calgary, Canada today.

John Bosher’s 12-year-old mare sustained a serious tendon injury during competition at Spruce Meadows on Wednesday.

A disappointed Tim strongly refuted rumors that she had been injured on the plane on the way over, stating: “I would never have competed her if she had been lame.

“She jumped clear in the first round of the grand prix qualifier, but two strides after the last fence she pulled up lame.

“At the moment, we are focusing on getting her home; once she is back we can look for the best way forward in terms of her care and treatment.

“Unfortunately it is a serious injury and so I think we are looking at about a year for her to recover fully.”

Corlato and Tim were part of the British team at the Beijing Olympic Games last year and last month’s European Championships at Windsor.

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A successful treatment for tendon injuries in horses is to be tested on people.

The pioneering stem cell treatment, developed by VetCell Bioscience in Cambridge, has been so successful in horses it will now be trialled on human beings with tendon injuries.

In tests on more than 1,500 horses with tendon problems, half were less likely to re-injure themselves over a three-year period if their tendons were injected with stem cells, as opposed to receiving only conventional treatments — like box rest, icing and anti-inflammatory drugs.

David Mountford, chief operating officer of VetCell Bioscience in Cambridge said: “It’s a very exciting development because if successful, it will greatly simply an athlete or football player’s route back to full fitness.

“In addition, the treatment could alleviate or cure long-term tendon injuries in older human patients, such as prolonged shoulder injuries.”

The stem cells, which are a basic form of cell before it has become flesh, bone or tendon, are derived from the patient themselves and not the more controversial embryo route.

The treatment implants millions of the patient’s own stem cells directly into the injured tendon or ligament to aid the body’s natural healing of the injury.

Mr Mountford said: “These are adult stem cells, so there’s no embryos involved. The horse or human will provide their own stem cells.”

The tests on humans will be focused on a notoriously tricky and often persistent injury for some, the Achilles tendon.

Professor Nicola Maffulli, a sports medicine and orthopaedic consultant said: “The move from clinical veterinary to human medicine is inspiring and unusual. We normally see the translation happening the other way around.

“I am very excited to be involved in the human studies and hope that the results will herald a new era in the treatment of musculoskeletal soft tissue injuries.

“At present the management of human tendinopathy [tendon injury] is more an art than a science but this approach could potentially reverse that situation.”

Human trials will begin in 2011.

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There can be no more contentious issue in the veterinary world than thermocautery or, as it is more commonly known, firing.

In AD 500, in the first written report of the firing of horse’s legs, Publius Vegetius Renatus doubts the efficacy of the procedure, and some 1,500 years later the practice still divides veterinary opinion.

Advocates argue that the operation, which is said to stimulate tendon repair by counter irritation and consequently help the healing process, can only be of benefit to both the patient and the owner. In most cases both legs will be treated simultaneously, even when only one shows a clinical problem. Those who are against the practice point to the barbarism of the actual act.

First the leg is clipped, the horse is sedated and a local anaesthetic applied. Then the patient is subjected to a red-hot firing iron placed against the lower leg. The iron will either be used to burn lines around the leg (known as line or bar firing) or punched into the leg to actually penetrate the tendon itself (pin firing) pictured above. Freeze firing using liquid nitrogen is a further alternative, while the practice of acid firing— this is sulphuric acid dabbed against the leg using a cork — has almost disappeared.

Firing dates back to the middle ages, when post-operative care would have been non-existent. Today, post-operative care for fired horses can be excellent with painkillers and sedation used to control pain and discomfort. But those who disapprove of the practice point to the fact that no research has ever concluded that firing is effective.

Firing is only one part of the whole treatment. Legs will need to settle from an injury before the operation can be performed. The post-operative care will result in enforced box rest, followed by walking in-hand for several weeks, or indeed months. Then the patient be ready for the horse-walker and then the field, to complete the rehabilitation process.

There is no getting away from the fact that the whole healing process cannot be rushed and the patient will be out of action for a minimum of a year. Opponents of firing latch on to this fact. Time is the greatest healer and there are many prominent vets who are convinced it is time that has cured the injury and not the invasive act of firing.

Research verses real life examples

“Professor Silver’s research on the subject at Bristol University is the most in-depth attempt carried out to prove or disprove the efficacy of firing,” says Peter Webbon MRCVS, chief executive of the Animal Health Trust. “Silver induced tendon injuries in ponies and carried out a five-year study comparing those treated by firing and those allowed to recuperate through rest. His findings appear to suggest that the efficacy of firing is limited.”

Silver concluded that the firing of tendon injuries did not improve the rate at which the ponies regained pre-injury soundness. Based on the lack of beneficial evidence from firing the legs of horses suffering from tendonitis, the Bristol University team concluded that firing was neither justifiable nor useful.

However, as with all contentious practices, those who have experienced beneficial results will continue to support its use. One example is Trevor Heath, head lad to Banbury trainer Paul Webber, who has spent a lifetime in racing and recalls the legendary Fred Rimell being a great advocate of the practice.

“When I was with Fred, we had a vet called Les Harris who used to acid-fire horses with tendon injuries. We had numerous horses who came back better than ever after the operation and Gay Trip won the Grand National in 1970 and was second in 1972, having been fired,” he says. “John Webber’s good horses, such as Elfast and Land Afar, had their best years here at Cropredy Lawn after being fired.”

Alan Walker points to another Grand National winner who had his finest hour after being fired twice.

“Jenny Pitman asked me to fire Royal Athlete once — and then got me back down there to do it a second time to get the job done properly,” he remembers. “The horse was a great patient and never looked back.”

The practice was banned in the UK briefly by the Royal College of Veterinary Surgeons in the early 1990s. But advocates of firing were vociferous in its defence and after protracted discussion, the Royal College agreed that firing could be used “but only when other methods have failed”.

• This veterinary feature can be read in full in Horse & Hound (4 January, ’07)

Elite event horses (intermediate level or above) are six times more likely to sustain an injury of the superficial digital flexor tendon compared with non-elite event horses, according to a recent study by the Animal Health Trust. Elite event horses also had a considerably higher risk of tendon injury compared with general purpose horses.

The study analysed all the clinical records of horses referred for lameness investigation between 1998 and 2003. Horses were categorised by the discipline in which they competed, or were described as “general purpose” (including those who competed only at unaffiliated competitions); whether they were “upper level” (elite competition horses) or “non-elite”; and the type of injury that caused their lameness.

National hunt racehorses and elite show jumpers (grade A or international horses) were also at a higher risk of injury to a superficial digital flexor tendon. Both elite and non-elite dressage horses were at particularly high risk of sustaining an injury to a hindlimb suspensory ligament.

Why do the injuries occur?

The elite-level show jumpers and dressage horses were older than the rest of the horses, while national hunt horses are older than flat racehorses. It is known that degenerative ageing changes occur in the tendons and ligaments and, thus, with increasing age these effectively become weaker and are more at risk of injury.

The biomechanical forces on the tendons and ligaments are also influential. For example, when galloping fast there will be over-extension of the front fetlocks, which places greater strain on the superficial digital flexor tendons than work at slower speeds. This places racehorses and upper-level event horses at potentially increased risk of injury.

For horses who jump, the higher the fences, the more strain placed on the forelimb superficial digital flexor tendons when they land. This may be another reason why elite-level show jumpers are at increased risk of injury.

It has been my clinical impression when working as a vet at one- and three-day events that tendon injuries have also been influenced by the going. When it has been wet and slippery or there has been deep, holding going, tendon injuries are more frequent than when ground conditions are ideal.

It will be interesting to see whether the loss of the steeplechase phase in three-day events decreases the frequency of tendon injuries in upper-level event horses, or whether the increasing demands of modern day cross-country courses will counterbalance this.

We are unlikely to be able to eliminate tendon injuries, but we must continue to work to understand better how the tendons and ligaments can be trained to minimise the risk.

Dressage horses

Although injuries of the upper part of the suspensory ligament in hindlimbs were more common than injuries lower down the leg in all disciplines, dressage horses were at particular risk of proximal suspensory desmitis.

Dressage horses are largely selected for training based upon the quality of their movements and their mental ability to be trained. The textbooks imply that at trot a horse moves in diagonal pairs, with the left hind and right forelimb hitting the ground simultaneously, followed by the right hind and left forelimb. However, this is not always the case and a proportion of the best-moving horses actually show advanced diagonal placement — that is, the hindlimb of a diagonal pair makes ground contact before the forelimb. This means that for a short period the horse is bearing all its weight on just one limb.

This effect may be magnified when the horse is working with increased levels of collection. This places increased strain on the suspensory apparatus. Slow motion video analysis has shown that, contrary to the rules of dressage, advanced diagonal placement occurs invariably in canter pirouette and frequently in high-scoring piaffe and passage.

A team at the Animal Health Trust, in conjunction with British Dressage, is currently investigating the relationship between arena surfaces and lameness. All owners of horses affiliated with British Dressage have been sent a detailed questionnaire asking the level at which the horse works, the frequency with which it is trained, the characteristics of the arena surface on which it works regularly, how the surface is maintained, how the arena surface alters under different weather conditions, and whether or not the horse has had any lameness — and if so, what was the underlying cause.

We hope that if enough of these questionnaires are returned we can develop some meaningful conclusions about what are the best types of arena surface properties to minimise the risk of injury. The validity of the conclusions are dependent on a high return rate, so we urge all members to complete a form for every horse, to enable us to make some progress in this important area.

This veterinary feature was first published in Horse & Hound (9 February, 2006)

Tendon injury is a major cause of lameness in athletic horses. Eventers and racehorses, particularly national hunt horses and point-to-pointers, are susceptible to injury of the superficial digital flexor tendon.

Until recently, the only scientific treatment for these injuries was prolonged rest to allow natural healing. Recent developments in tissue engineering have enabled stem cell technology to be used to treat tendon and suspensory ligament injuries.

Stem cells are immature cells produced by the body that grow into whatever type of cells are required to replace old or diseased ones. The horse is able to fend off the effects of ageing and recover from injury and disease by the growth and differentiation of stem cells.

Stem cell therapy involves harvesting stem cells, usually from the bone marrow of the horse to be treated. This tissue is sent to a specialist laboratory, where the stem cells are selected and multiplied by cell culture.

The purified cell sample is then transported back to the vet supervising the treatment, who injects them into the injury site. Here, the stem cells will develop into tendon cells and produce new tissue to replace the damaged tendon.

The whole science of tissue engineering is very new in both the medical and the veterinary world. Scientists are still learning about the best ways to purify and treat stem cells to ensure as many as possible turn into tendon cells and assist the process of repair.

Trials to evaluate the effectiveness of this treatment are also in their early stages. Although there have been some well-publicised successes, it is too early to state with absolute certainty that this method of treating strained tendons is better than rest alone.

Scientists will continue to evaluate stem cell therapy as a treatment for tendon injuries and, within a few years, it should be possible to determine the true benefits of treatment.

• This veterinary feature was first published in Horse & Hound (12 January, ’06)

The correct diagnosis and treatment of orthopaedic infections (infections located anywhere inside or on the outer surface of the limbs) is challenging to any vet.

Long-standing infections involving vital structures such as bones, joints and tendon sheaths can be particularly difficult to treat, with less than 50% of infected equine fractures healing successfully.

Most commonly seen are infections of synovial cavities (joints, tendon sheaths and bursae) which can be career ending or even life threatening. Some long-standing synovial infections will be virtually untreatable and cause such severe pain that the horse has to be put down.

Do not delay in seeking veterinary advice with any injury, which might be infected. The longer the synovial infection is present, the more difficult and costly it will be to treat, and the more likely it is to result in permanent lameness.

It is always best to remember that what at first appears to be a minor injury can end up as the most serious. Any deep puncture wounds should be considered as much of an emergency as larger wounds. A puncture into a joint or tendon sheath can cripple a horse, as these structures cannot combat infection and require intensive treatment.

Diagnosis

If there is obvious lameness and a deep wound close to a joint, tendon sheath or bursa, a vet should be contacted urgently. The vet then has to decide if the injury is minor, or more serious and likely to develop into a serious orthopaedic infection.

It can be difficult to be certain because a wound that has penetrated a joint, tendon sheath or bursa is likely to look like any other injury. Most wounds that cause major infections appear minor and innocuous initially, apart from their position. The majority of horses are lame but the degree of lameness is variable.

If there is any serious concern that a joint or similar has been infected, the vet will do further special diagnostic tests to establish the seriousness of the condition.

Theses can include:

• taking a fluid sample from the joint or tendon sheath to look for signs of infection
• x-rays or scans to find out what is happening inside the joint
• laboratory tests on infected joint fluid to find out how severe the infection is

Treatment

If a joint or other delicate tissue is infected, the horse is likely to require a general anaesthetic and surgery to clean the affected area. For a joint or tendon sheath this will involve flushing litres of sterile saline through the damaged area to eliminate the infection.

It may be difficult to remove everything at once and to be successful the flushing has to be done before any permanent damage has occurred. Repeated flushes and intensive courses of antibiotics may be needed. With a survival rate of 90%, and 81% returning to their previous level of performance, the outlook is always guarded in these cases.

This article was first published in Horse & Hound (29 January 04 issue)

The tendon and ligament structures at the back of the pastern are particularly liable to strain injuries, which are commonly caused by over twisting the limb while bearing weight or over extending the lower limb joints.

Damage to one of the branches of the superficial digital flexor tendon is the most common injury, followed by strain of one of the oblique sesamoidean ligaments, although both can be difficult to diagnose.

While these injuries sometimes result in soft tissue swelling on the back and to one side of the pastern, in some horses there is no detectable swelling and there is no signs of pain when firm thumb pressure is applied to the back of the pastern.

Definitive diagnosis is normally based on scans, after the pain has been localised through nerve blocks. It can be difficult to desensitise the entire foot without removing pain from the pastern region, which complicates matters further. Sometimes it is only by the progressive elimination by nerve blocks of the coffin and pastern joints, and by X-raying the foot with negative findings that the injury is found.

Superficial digital flexor tendon injuries are most common in horses that have previously strained the tendon in the cannon bone region, but they can occur without earlier injury.

The tendon branches lie inside and outside the deep digital flexor tendon and, if they are markedly enlarged, it is usually possible to detect the swelling. However, in very recent injuries there may be no swelling or the tendon may be masked by overlying fibrous swelling.

Injuries to the sesamoidean ligaments frequently occur with no detectable soft tissue swelling. Skilled scanning by an experienced vet is essential for definitive diagnosis and to provide an accurate prognosis for pastern, tendon and ligament injuries.

Typical trauma

A direct blow to the back of the pastern may result in severe bruising of the soft tissues and fibrous tissue formation, resulting in a firm lump. While the horse may be lame after the injury, long-term lameness is unusual.

A cut on the back of the pastern is much more serious. Contamination of the tendon sheath must be considered an emergency, because without rapid aggressive treatment, life-threatening infection can develop.

A complete cut through the deep digital flexor tendon will result in the toe of the foot flipping up during weight bearing and partial dislocation of the coffin joint. This is usually a career-ending injury.

A cut through a branch of the superficial digital flexor tendon doesn’t usually result in posture change, but tends to repair by fibrous tissue formation, which can compromise free movement of the tendons and ligaments and therefore causes long-term lameness.

This information was originally published in the 4 September issue of Horse & Hound.

The two small bones that lie at the back of the fetlock joint are called the sesamoid bones. These bones play an important role as part of the suspensory apparatus supporting the fetlock joint. This apparatus also includes ligaments that lie at the back of the cannon bone and pastern.

The suspensory apparatus acts like a sling on to which the fetlock joint sits and, as a result, much of the weight of the horse. This system allows the horse to bear weight without having to use much muscle effort.

Slow-motion videos of horses galloping demonstrate why the suspensory apparatus is vulnerable to injury. At high speeds the fetlock “drops” close to the ground because much of the horse’s weight is taken by the “sling” of the suspensory apparatus.

The forces on to the bones and ligaments of half-a-ton of horse galloping at 45mph are considerable, and it is not surprising that injuries commonly occur. They can occur anywhere along the length of the ligaments and bones of the suspensory apparatus.

Sesamoid injuries are common following trauma, such as kicks or strains, and are most common in horses regularly working at fast speeds, such as racehorses.