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Rehabilitation of the equine athlete
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Summary
Musculoskeletal injuries are common in race and sport horses. The major causes of them are the repetitive biomechanical stresses placed on the joint surfaces, subchondral bone and ligaments. Sometimes an acute extra-physiological movement may be responsible for damages in the joint. In complement to medication, rehabilitation is an essential part of the management of joint problems in horses. Corrective shoeing, selection of adequate ground surfaces, adequate level and type of exercises are the key-factors to manage for bringing the horse back to the expected level of activity and performance.
Key-words: rehabilitation, horse, joint, tendon.
Introduction
Musculoskeletal injuries may have major interference with the athletic career of race and sport horses. Once an accurate and complete diagnosis is made, the management and rehabilitation programme are based on the type and severity of the clinical manifestations, the understanding of the etiopathogenesis of the horse conditions.and their respective expected healing progress.
Design of a rehabilitation programme begins with an accurate diagnosis
An accurate diagnosis of the affected joint(s), the affected structure(s) within the joint(s) and a good documentation of the evolution stage of the lesion(s) are critical for designing an appropriate rehabilitation programme. It is essential to select the gait(s), speed, specific exercises and to establish an appropriate exercise level in parallel to an adequate monitoring of the problem and the patient tolerance.
Knowledge of the biomechanics of the affected structures
An adequate rehabilitation programme consists mainly in manipulating the biomechanical stresses on the injured structures. Theses stresses must be reduced for acute or painful injuries and must be progressively adjusted to healing or pain level. In order to achieve this the exercise programme must be specifically adapted to every particular condition. For example, in a horse presenting an acute or subacute grade 2 or 3 desmopathy of the medial collateral ligament of the left distal interphalangeal joint, every turn on the left, at any gait is contra-indicated for at least 2 or 3 months (depending on data obtained from clinical and ultrasound follow up) to avoid lateromotion of the joint and tension of the affected ligament. This horse will be exercised at the walk and trot on straight lines and open right turns.
Corrective shoeing for rehabilitating joints
Corrective shoeing is a unique modality for manipulating the biomechanical stresses on the affected structures. A specific corrective shoeing programme can be rationally set up for each type of joint and ligament injuries in the equine distal limb taking into account the precise nature of the anatomical structure(s) involved, the evolution stage of the lesion(s) and repair process. For most of the joint problems rehabilitation will be performed on a soft and even surface. Corrective shoeing is also used to prevent joint injuries in horses with conformational defects.
1- Subchondral bone injuries
Subchondral bone trauma or cysts can be induced by chronic or acute overload of the joint surfaces in a specific location. Pressure on the diseased part of the joint may induce pain or worsening of the lesion. The objective of the corrective shoeing is to reduce pressure on the affected subchondral bone and distribute the load on the other sounder parts of the joint surfaces.
Therefore for horses presenting subchondral bone edema, lysis, sclerosis or cyst-like lesion on the medial part of a condyle or glenoid cavity, our goal is to reduce mediomotion (Denoix 1999) and distribute the load laterally using a corrective shoe with a narrow medial branch (with a bevel on the outside rim) and a wide lateral branch to provide more support laterally. The opposite is recommended for lateral subchondral bone injuries. Lateromedial and dorsopalmar radiographs proved to be useful for the assessment of joints balance in order to help for adequate foot trimming.
2- Collateral desmopathies
Corrective shoeing is also an essential part of the management of desmopathies of the equine distal limb. The precise knowledge of the joint movements is required for corrective shoeing of sound as well as lame horses. An adequate trimming and shoeing programme requires a precise diagnosis of each injured structure, based on radiography, ultrasonography and/or magnetic resonance imaging.
The objective of the shoeing programme for collateral ligament injuries is to reduce tension of the injured structure.
This can be achieved through the control of collateromotion (Denoix 1999), sliding and rotation of the affected joint. For an injury of the medial collateral ligament the corrective shoeing consists in providing more support (wider branch) on the side of the lesion, with improved rolling effect on the opposite (lateral) side. The reverse is recommended for lateral collateral injuries. As support to the heels increases interphalangeal joint flexion and fetlock extension, egg bar or reverse shoes are not recommended for metacarpophalangeal collateral desmopathies.
All the anatomical structures of the distal limb are highly stressed during weight bearing and especially during the stance phase on uneven ground or asymmetric foot placement. Therefore, a soft and regular ground surface must be selected for the rehabilitation of distal joint injuries. Turns should also be limited and exercise in lunge is contra-indicated.
3- Desmopathies of the podotrochlear apparatus
They may involve the collateral sesamoidean ligaments, the proximal and distal sesamoidean ligaments and the distal digital annular ligament. When symmetrical, the principles and recommendations are similar to the corrective shoeing used for deep digital flexor tendon injuries (Chateau et al 2006). Asymmetrical injuries need manipulation of the lateromedial balance of the shoe.
Corrective shoeing for rehabilitating tendons
Management of tendon injuries is based on a precise documentation and follow up of the lesion(s) and a complete initial evaluation and reassessment of the horse locomotion. Rehabilitation is based on adequate corrective shoeing (Denoix 1994), selection of appropriate surfaces and gaits and progressive increase of the exercise level (speed and gait, Denoix and Crevier-Denoix 1997). Swimming or aquatreadmill exercises may help to maintain appropriate body condition without putting overstresses on the affected tendon(s).
Basic approach for rehabilitating joint and tendon injuries
1. Avoid worsening of the lesions through inadequate management of the biomechanical stresses on affected structures; avoid to do blocks (nerve or intrasynovial) if there is any suspicion of bone or ligament injury.
2. Reduce pain: the rehabilitation programme can be undertaken while the injured structure is at rest without supporting major biomechanical stress. This is achieved using corrective shoeing, selection of exercise surface and exercise programme. Shock waves and laser therapy may be helpful.
3. Reduce inflammation: cold therapy (packs + water).
4. Improve healing. There is still little evidence of the efficacy of medications (general or local) compared to the spontaneous evolution of the healing process. The bone heals spontaneously; the cartilage has little healing capacity; the ligaments heal except if they present an intrasynovial rupture. Progressive mechanical stimulation of the affected structures remains the most adequate in order to reach the ultimate functional restoration of these structures.
5- Improve functional properties and promote joint mobility. Once the healing process is sufficiently advanced, a progressive rehabilitation programme with regular increase of the duration and intensity of exercises is set up. This must be done taking into account the type of joint lesions presented by the patient. For traumatic desmopathies, once the healing has been achieved, the horse can gradually return to a full exercise programme. For degenerative conditions (cartilage injuries, some enthesopathies), stressful situations must be avoided during training. For subchondral bone lesion, exercises putting load on the affected articular surface will be limited. Again, monitoring clinical manifestations and imaging evolution regularly is essential for adjusting the exercise programme.
6- Conditioning and body status. One important aspect of the exercise programme is to maintain a good physical condition and avoid over-weight. The exercise duration must be adapted to these objectives. Swimming, treadmill or aquatreadmill may also contribute without putting too much stress on the distal joints.
Conclusion
Corrective shoeing is essential for the management of joint and tendon injuries in race and sport horses. It allows us to manipulate the mechanical stresses undergone by the subchondral bone and collateral ligaments at each step of the healing process and to facilitate rehabilitation and reconditioning. A careful selection of the adequate ground surface and physical exercises must be done based on the knowledge of the biomechanical stresses placed on every injured structures of a specific joint. Manipulation of the training programme combined with a good clinical and imaging follow up of the patient allows managing most of the joint conditions in sport and race horses.
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[1] Denoix J.-M. (1999) Functional anatomy of the equine interphalangeal joints Proceedings 45th Annual Convention American Assoc. Equine Pract, 174-177.
[2] Chateau H. et al (2006) Three-dimensional kinematics of the distal forelimb in horses trotting on a treadmill and effects of elevation of heel and toe. Equine Vet. J., 38, 164-169.
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