Lameness: Tendon and Ligament Problems Articles

Healing the Bowed Tendon

The Lowdown on High Suspensory Disease (Proximal Suspensory
Desmitis)

Healing the Bowed Tendon
by Maria L. Lewis, VMD
When people say a horse is "bowed" or that it has a "bowed tendon" they are generally
re!erring to tearing o! the super!i"ial digital !lexor tendon in the middle o! the "annon bone region#
This tear "auses a "ur$ed bow%li&e swelling on the ba"& o! the leg between the &nee and the
an&le# 'lthough the swelling is usually in the middle o! the "annon bone it may be behind the
&nee at the le$el o! the an&le or it may extend !rom the &nee to the pastern# (ost people thin&
tendon in)uries su"h as "bowed tendons" only happen to ra"ehorses# *n reality any breed or type
o! horse per!orming almost any a"ti$ity "an be at ris& !or tendon in)ury# Tendon in)uries "an be
more serious than some types o! !ra"tures be"ause the tendon heals $ery slowly and repla"es
torn tendon !ibers with !ibrous s"ar tissue# The healed tendon is less elasti" lea$ing the tendon
$ulnerable to re%in)ury# When there is a signi!i"ant in)ury the horse may not be able to return to its
pre$ious le$el o! per!orman"e due to persistent wea&ness o! the tendon#
The super!i"ial digital !lexor tendon is made o! protein !ibers that are arranged longitudinally
!orming a long atta"hment between the mus"le abo$e the &nee and the long and short pastern
bones )ust abo$e the hoo!# The tendon !ibers are somewhat elasti" but will tear i! stret"hed or
loaded beyond their limits# *mproper positioning o! the leg in relation to the horse+s body weight
"an tear the tendon !ibers# This "on!iguration may o""ur when the horse lands a!ter a !en"e or as
the horse be"omes tired and "hanges its gait# 'ny unbalan"ed loading o! the tendon une$en
!ooting poor "on!ormation and,or improper shoeing "an also "ontribute to tendon damage# *n
some "ases this o$erload "an be the result o! a single misstep and in other "ases it "an be the
result o! "umulati$e stress or !atigue o! the !ibers#
-n"e the tendon !ibers tear bleeding within the tendon "auses a"ute swelling heat and pain#
The horse may or may not exhibit lameness# *n !a"t many horses with serious tendon damage
are ne$er lame# Swelling also o""urs around the tendon due to an a""umulation o! !luid (edema)#
*n the short term i"e or "old hosing and bandaging the leg should de"rease the lo"al
in!lammation and swelling# The horse should be "on!ined to its stall with only hand wal&ing
exer"ise# *! the horse is sore or signi!i"ant swelling is present "onsider spea&ing to a $eterinarian
about using oral phenylbuta.one !or a short period o! time to de"rease the swelling and
dis"om!ort# Sin"e palpation o! the leg is not a reliable method o! determining the presen"e o!
tendon damage "onta"t a $eterinarian to ma&e arrangements !or an ultrasonographi" e$aluation
o! the swelling#
/ltrasonography allows a $eterinarian to e$aluate the integrity o! the tendon !ibers as well as
other important parameters in"luding the "ross%se"tional area o! the tendon the alignment o! its
!ibers and its e"hogeni"ity# The e"hogeni"ity o! the tendon is related to its density# The0 normal
tendon appears bright white or e"hogeni" and the abnormal tendon appears $arious shades o!
gray (hypoe"hoi") or bla"& (ane"hoi")# Based on the ultrasonographi" !indings a $eterinarian "an
"on!irm the presen"e o! tendon damage and determine its se$erity# Subtle tendon damage may
display an in"rease in the tendon "ross%se"tional area due to edema without a"tual !iber tearing#
Serious damage may "onsist o! total tendon rupture with "omplete loss o! the tendon !ibers a
mar&ed in"rease in tendon "ross%se"tional area and loss o! support in the limb# (ost tendon
in)uries !all somewhere in between with a dis"rete area o! !iber tearing $isible on the ultrasound
image (bla"& or dar& gray hole) and enlargement o! the total tendon "ross%se"tional area# The
hole seen on the ultrasound is a"tually an a""umulation o! blood and granulation tissue within the
tendon where the tendon !ibers ha$e torn apart#
*! your horse has su!!ered a tendon in)ury a $eterinarian will wor& with you to de$elop a
rehabilitation plan# (ost horses need stall rest with restri"ted exer"ise !or at least two months
(possibly up to eight months) depending on the degree o! in)ury and the horse+s temperament#
This "on!inement "oupled with a "ontrolled exer"ise program will en"ourage healing o! the
tendon while pre$enting re%in)ury# *nitially the horse should only be wal&ed in hand# -n"e the
tendon has been "ooled out "old hosing is no longer ne"essary or help!ul# Topi"al appli"ation o!
D(S- may help de"rease residual swelling in the leg but the tendon will remain persistently
thi"&ened in the ma)ority o! "ases#
' $eterinarian will need to ultrasound the horse+s leg approximately e$ery sixty days a!ter the
initial exam to determine i! the tendon has healed enough to allow !or an in"rease in exer"ise# 'n
in"rease in exer"ise may entail up to !i$e minutes o! )ogging exer"ise or turnout in a small
paddo"&# This exer"ise will gradually in"rease o$er a period o! months1 depending on the
impro$ements seen during the !ollow%up ultrasound exams# Tendon rehabilitation is a slow
pro"ess that "an be !rustrating i! your horse su!!ers any setba"&s due to re%in)ury# (onitoring the
horse+s progress with regular ultrasounds "an eliminate these setba"&s#
2e"ent resear"h in $eterinary medi"ine has !o"used on ways o! impro$ing the out"ome o! tendon
in)uries# Surgi"al treatments that in"lude tendon splitting and superior "he"& ligament desmotomy
ha$e been !ound use!ul# -ther treatment modalities su"h as therapeuti" ultrasound low%power
laser a"upun"ture hydrotherapy and ele"tromagnets are also thought to promote tendon
healing# *n some "ases the use o! intralesional medi"ation su"h as '34LL may be bene!i"ial in
impro$ing the 5uality o! tendon repair# ' $eterinarian "an help "hoose the best treatment !or ea"h
indi$idual horse#
'lthough tendon in)uries are serious most horses "an re"o$er and return to athleti" !un"tion i!
gi$en enough time# 4$en in the "ase o! a se$ere tear it is li&ely that a horse will be able to return
to a less strenuous a"ti$ity# The best way to ensure a su""ess!ul out"ome is through prompt
ultrasonographi" diagnosis treatment and "are!ul monitoring o! the tendon by a $eterinarian#
Dr# Lewis a 6776 /ni$ersity o! Pennsyl$ania S"hool o! 8eterinary (edi"ine graduate is "urrently
in pri$ate pra"ti"e limited to e5uine diagnosti" ultrasound in /nion$ille P'# She trained in
diagnosti" ultrasonography with Dr# 8irginia 2ee! at 9ew Bolton 3enter !or se$eral years1 and
ser$ed as an *maging Spe"ialist at the 677: 'tlanta -lympi" ;ames and at the 6777 Pan
'meri"an ;ames in Winnipeg#
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The Lowdown on High Ss!ensory Disease "Pro#imal
Ss!ensory Desmitis$
by Se Dyson, %&'VS, AA(P member

Sue Dyson H238S ''4P member

)*T&+D,'T)+*
The suspensory ligament "an be di$ided into three separate regions all o! whi"h "an be"ome
in)uredE the proximal (upper) part the body and the bran"hes# Proximal suspensory desmitis
(PSD) or high suspensory disease is a "ommon in)ury in both the !orelimbs and the hindlimbs o!
athleti" horses and may o""ur in one limb or in both the !orelimbs or both the hindlimbs at the
same time#
LAM(*(SS (-AM)*AT)+*
Proximal suspensory desmitis in the !orelimb results in a sudden onset o! lameness whi"h "an be
remar&ably temporary resol$ing within =? hours unless the horse is wor&ed hard# Lameness
$aries !rom mild to moderate and is rarely se$ere unless the lesion within the ligament is
extensi$e# PSD in both !ront limbs may result in loss o! a"tion rather than obser$able lameness#
This o""urs more "ommonly in ra"ehorses probably be"ause o! the !ailure to re"ogni.e earlier
subtle lameness o! )ust one limb#
Lameness is usually worse on so!t ground espe"ially with the a!!e"ted limb on the outside o! the
"ir"le# When subtle the lameness may be more easily !elt by a rider than seen by an obser$er#
Lameness may not be apparent at wor&ing trot but may be dete"table at medium or extended
trot# Hlexing the lower limb o!ten temporarily worsens the lameness# *t may be undesirable to
wor& the horse hard to reprodu"e lameness be"ause o! the ris& o! worsening the in)ury#
*(&V( BL+'. "L+'AL D)A/*+ST)' A*AL/(S)A$
*! PSD is suspe"ted lo"al diagnosti" analgesia is indi"ated# This should result in
substantial impro$ement in or "omplete alle$iation o! lameness within about 6>
minutes assuming PSD is the only "ause o! lameness# Howe$er none o! the
di!!erent ways o! blo"&ing the proximal suspensory ligament are ne"essarily
spe"i!i"# That is pain in other stru"tures su"h as the &nee or !oot may also be
alle$iated# -n the other hand it is possible !or the blo"&ing solution to be in)e"ted
into stru"tures next to the proximal suspensory ligament# Thus e$en i! the
lameness was not impro$ed or alle$iated with a PSD blo"& the lameness may
still be due to this "ondition#
,LT&AS+*+/&APH0
Diagnosti" ultrasonography is essential to a""urately diagnose PSD# The limb should be
e$aluated in two di!!erent planes and "are!ul "omparisons should be made to the
opposite limb# High 5uality images are needed sin"e lesions "an be subtle and easily
missed# (easurements o! the ligament may be extremely $aluable sin"e espe"ially in
a"ute "ases enlargement o! the ligament may be the only dete"table ultrasonographi"
abnormality# *t may be di!!i"ult to e$aluate an a"ute "ase a""urately i! the horse has had a
pre$ious in)ury to the suspensory ligament be"ause the tissue may not ha$e healed !ully#
'lso lo"al diagnosti" analgesia may allow air to enter the area ma&ing $isuali.ation
di!!i"ult#
The degree o! ultrasonographi" abnormality usually re!le"ts the se$erity o! the lameness#
*n a"ute "ases the ultrasonographi" abnormalities may be $ery subtle# Sin"e they may
worsen o$er the next 6> to 6? days re%e$aluation may be use!ul to "on!irm the diagnosis#
+TH(& )MA/)*/ T('H*)1,(S
There are usually no dete"table radiographi" abnormalities o! the "annon bone in a"ute
"ases o! PSD# *n "hroni" "ases howe$er "ertain parts o! the bone may appear "whiter" or
"dar&er" in "ertain $iews# When these se"ondary bony "hanges o""ur in a !orelimb a
more guarded prognosis is gi$en# 9u"lear s"intigraphy is generally unne"essary !or
diagnosis i! good 5uality ultrasonographi" images are obtained but it may add
in!ormation about se"ondary bony "hanges#
*t should be &ept in mind that there may be more than one sour"e o! pain "ontributing to
lameness# Hor example PSD and !oot pain o""ur together 5uite "ommonly# There may
also be hindlimb lameness o""urring at the same time as PSD espe"ially in the opposite
hindlimb so it is important both to assess and to re%e$aluate the horse as a whole#
T&(ATM(*T
(ost "ases o! a"ute !orelimb PSD respond well to stall rest and "ontrolled wal&ing exer"ise !or
three months# 'ttention to "orre"t !oot balan"e is important# 'lthough starting the horse ba"& to
wor& too soon usually results in re"urrent in)ury approximately 7>L o! horses do resume !ull
athleti" !un"tion without in)uring themsel$es again# (ore "hroni" "ases may re5uire longer
rehabilitation1 in a small proportion o! "ases lameness persists# 4xtra"orporeal sho"& wa$e
treatment has been su""ess!ul in some "hroni" "ases whi"h had !ailed to respond to "onser$ati$e
management#
*n some horses the lesions disappear "ompletely upon !ollow%up ultrasonography# *n others the
appearan"e o! the suspensory ligament ne$er returns to normal# 2est should be "ontinued until
the appearan"e o! the ligament on ultrasound remains stable#
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