Tendon & Ligament Injuries DIAGNOSIS Diagnosis of tendon and ligament injuries is based primarily on clinical and ultrasound findings. The typical signs of injury are heat, swelling and pain when palpating the structure. Ultrasound is an important next step to evaluate; 1.The severity of the damage 2.What tendon/ligament is damaged and the location of the damage within it SDFT DDFT SL
This scan will dictate what treatment is required and the appropriate time required for healing and future prognosis. It will help indicate how much time the horse will need to resume normal work. This scan will be saved and used to evaluate healing response on successive scans. TENDON / LIGAMENT HEALING When tendons and ligaments heal the damaged fibres are replaced by scar tissue. Scar tissue takes approximately 90 days to form and then it takes approximately 10-12 months to gain its maximum strength. Scar tissue will never be as strong as the original normal tissue. As an example, where there is only 10% fibre damage horses will still have 90% normal tissue strength and are likely to return to work sooner with a reasonable prognosis. For cases where there is 90% damage to fibres the horse will be returning to work with only 10% normal fibre strength and 90% scar tissue so it will warrant a longer period to heal with a poorer prognosis for future performance. GOALS OF TREATMENT Gone are the days of bushing horses into a large acreage paddock after a tendon/ligament injury then returning them to work 12 months later. Several advances in treatment have been made to improve the strength of the scar tissue after it has formed at the 90-day mark. These improved treatments allow us to; Get the horse back to work more quickly Minimise the risk of reinjury once exercise is resumed REHABILITATION Each individual case will require specific treatment protocol tailored to its particular needs. Factors that will be considered include the severity of injury, the horse s intended use, and whether this is a new injury or re-injury. All treatment protocols will consist of a Rehabilitation period, Return to Work period and Other Treatment Modalities. We strongly discourage turnout during the initial post injury period as it greatly predisposes the horse to re-injury. A typical protocol for the rehabilitation period and first 90 days looks as follows; Week 1-2 Month 1 Month 2-3 Stall Rest phenylbutazone, icing of the limb, bandage support of the injury, ultrasound assessment of the injury. Stall Rest daily hand walking or walker walking. Start at 5 minutes and increase by 5 minutes each week. As the scar tissue fibres are created they will respond to applied stress. If there is a small but consistent amount of stress along the length of the limb then the collagen fibres will respond by lining themselves up in an attempt to accommodate this tugging on either end. Small Yard Rest A yard 2-3 times bigger then the stall size to allow slightly more movement. Hand walking should continue during this period. At the end of this period rescan the injury to assess healing and determine whether more rest is required or the addition of other therapeutic strategies should be implemented. BACK TO WORK
If the scar tissue appears adequately mature and organised during the follow up ultrasound evaluation, and the original injury was not too serious, at the 2-3 month mark then a Back to Work schedule may be implemented for the horse. The idea of the back to work period is to apply stress to the new scar tissue that has formed in a way that it to remodel and adapt but does not predispose it to reinjury. This is achieved by introducing workload at gradual increments. Generally, lesions will need the same amount of time to strengthen in a Back to work schedule as they needed in the initial stall rest period. The timing and progression of this stage is variable and guided by rescans ideally performed every 6-8 weeks. Month 4 Month 5 Month 6 Walking under saddle for 2 weeks daily straight lines, flat surface for 15mins. Then add trotting under saddle for 2 weeks starting with 5 minutes daily and increasing by 5 minutes each week. Trotting work on a flat surface in mostly straight lines, building up to 20-30mins. Increasing increments of overall work session time. Can add cantering under saddle, starting with 5 minutes and increasing to 15mins over the month. Gradually increase varied surface and circle work after 2 weeks. Gradually introduce jumping up to 40cm in 4 th week. OTHER TREATMENT MODALITIES In some cases we recommend adjunctive treatment modalities designed to Accelerate the healing process Improve scar tissue strength and function Platelet Rich Plasma is an autologous concentration of platelets in a small volume of plasma. Platelets are responsible for secreting the 7 fundamental protein growth factors for wound healing. Injecting a concentrated amount into the area of injury greatly promotes stem cell function within tendons and ligaments and increases healing rates. Additionally it is easy to collect and unlikely to produce an immune reaction (unlike other stem cell products) due to its autologous nature (produced from the patient s own blood). It can be used for tendon injuries, muscle strain, ligament strain, arthritis, articular cartilage defects, meniscal injury, chronic synovitis. The best injuries to treat are those with a central defect that allows the PRP to be contained within the lesion. This treatment is usually performed around 2 weeks post injury. IRAP Interleukin-1 receptor antagonist protein is the use of the body s own inflammation fighting cells to reduce inflammation. This is derived from the patient s own blood and infused in to the tissue defect to minimise inflammation and improve healing. Similar to PRP this product has the desired healing effects without the unwanted side effects found with commercially produced injectable medications. IRAP is used more commonly in tendon/ligament injuries that are within joints or osteoarthritis.
Infrared Laser Laser stands for Light Amplification by Stimulated Emission Rays. Lasers direct highly concentrated light at a specific wavelength to muscles, tissues, organs and connective tissue. Light from a laser induces specific biological changes in the tissue, including: * Altered electrical activity in the cells * Increased circulation to affected tissues * Increased lymphatic drainage * Increased supply of oxygen and other nutrients to diseased tissue * Increased microcirculation for healing We have had an encouraging response with laser treatment. Generally multiple treatments are recommended at an interval of every second day, to begin with. Lasers can be used in the early period to reduce swelling and pain (first few weeks), and later to stimulate healing (from 1 month). Lasers can be hired from the clinic to achieve this frequency. Shockwave Therapy is the application of sound waves to treat a musculoskeletal injury. Shock waves are directed through a hand-held probe which is moved over the skin of the affected site after applying the ultrasound gel. The sound waves are given as short pulses of less than 1 microsecond. Treatment usually involves 1000 to 4000 pulses. Thus the treatment takes only 15 to 30 minutes. The number and intensity of the sound waves will depend on the severity of the conditions. Treatment may require three or more sessions of therapy. The shock wave stresses the tissues especially at tissue interfaces ie between bone/tendon/ligament. This stimulates remodelling and healing promoting a host of benefits such as; new blood vessel formation, stimulation of collagen production, dispersal of pain mediator substance P, dissolution of calcified fibroblasts and reversal of chronic inflammation. Shockwave therapy is widely used in human sports medicine due to its multiple benefits. We recommend implementing this treatment starting at approximately 30-45 days post injury.
A TREATMENT PLAN A typical tendon/ligament treatment plan consists of; 1. Initial injury and consultation with an ultrasound scan. 2. Intralesional injection of the injury site PRP or IRAP. 3. Stall rest and hand walking for 4 weeks. Some horses may need sedation to keep them calm during this period to avoid reinjury. Laser therapy may be used during this period. 4. Shockwave therapy starting at 30-45 days approximately 3 treatments 1-2 weeks apart. 5. Clinical ultrasound re-examination performed at the end of stall rest period to confirm that desired healing has occurred and determine if exercise can start. 6. Resume Exercise with a back to work schedule to strengthen the tendon/ligament in incremental phases. Repeat ultrasound scans at 6-8 week intervals determine the progression of this phase.