Sports related injuries are common in equine competitions and training. They are expected to occur and are likely, due to the extreme stress placed upon joints and other supporting structures, often exceeding normal limitations. The injuries can be a short term nuisance or many prove to be long term, career ending problems that drag on for years. How we approach these injuries from both a preventative and therapeutic perspective can dictate the outcome and often improve our odds of success. In order to understand the options before us, we have to understand what is taking place within that animal.
Injuries are to be expected with any horse, whether if that animal is a top level competitor or just a pasture companion. They easily occur as a result of a kick, slip, fall, mistep or improper landing. In the world of equine sports, it is not hard to see how or why these injuries occur. We can watch a barrel racer turn sharply around barrels, twisting and contorting joints. In jumpers or even a racing QH or TB , all we have to do is slow down the video and watch the full stress load on the fetlock, carpus and flexor tendons upon landing. Joints, muscles, tendons and ligaments are all highly stressed, no matter the sport, but to each sport we have a higher stressload in certain areas. However, despite the differences between sports, an injury is an injury and can prove to be a very frustrating problem to contend with. In most cases of injury, we often resort to cold hosing, pain medications, linaments, poultices, injections, braces, confinement and other forms of therapy to aid in recovery.
Many respond well, over time, but the ultimate question is whether or not we are doing enough? Our efforts are often revealed in terms of success, when we look at the recurrence rate. How often does that injury come back? In many, this rate is high, often well above 50%, in which case that animal's soundness and future performance is greatly inhibited. To some trainers or owners, they continue to push forward, often relying on more medications to numb that pain and allow the animal to push through. Is this correct logic? Is this the right move for the animal considering future health? Is this even the right move for the rider, considering risk involved with potentially riding an unsound horse and potential harm?
In any injury, we really have three phases of healing that must take place in sequence:
- Remodeling or Maturation
The inflammatory phase is the first phase to occur post acute injury and results in the cardinal signs of heat, pain, swelling, redness and loss of use. This phase is a necessary phase as it is protective to an extent. Through the perception of pain and even swelliing, use of the affected area is limited, which acts as a protective mechanism against further damage. We don't want to be running around on a damaged flexor tendon or damaged joint. The pain almost forces less use, forces rest. The acute inflammatory process also results in increased circulation of blood to the damaged area, which also brings with it immune related cells to aid in defense against bacterial invaders but also serve to clean up dead or damaged tissue. This acute inflammatory phase is needed and generally lasts a couple days to a week, in most cases, but it can continue longer. In some injuries that tend to linger, the acute inflammatory phase becomes extended, becoming chronic, which can actually be destructive and harmful to normal tissue and the healing process. Inflammation, in regards to injuries, is meant to be short lived. Do the job it is supposed to do, then retreat. The way we approach that injury can either help us or even harm us, in our efforts to bring back our equine athlete.
In some cases, medication use can work both ways, for us or against us. The reason being is that most anti-inflammatory medications are overly targeted to certain aspects of the inflammatory process, so they can actually block key areas of healing and recovery. This may then prolong the injury due to lack of proper healing response. Diet can also play a major role in the inflammatory phase, in which cases, some diets that are higher in omega-6 fatty acids or even some commercially available feeds, may actually prove to be pro-inflammatory in nature and add to the situation rather than help it.
Bottom line, we want that acute inflammatory phase, we need it, but it needs to be controlled to a certain extent. The longer it persists, the more damage that is occuring and the more likely that injury recovery is to be prolonged.
The proliferation phase is the second phase of injury recovery, coming into play as the inflammation dies down. During this phase, nutrients are brought in to the affected tissue with the goal of improving cellular health and tissue repair. Cells are quickly dividing, repairing defects with collagen, which acts as a scaffold of sorts for tissue repair. New granulation tissue is laid down to aid in repair and along with that, new blood vessels are formed to deliver proper blood circulation. As a part of this process, dead or dying tissue must first be removed, which is often the job of the immune response. The metabolism or energy production within that animal is at a high level during this time, dependent on the severity of the injury, and the entire body has an increased need for proper nutrients and overall calories to fuel the process. The proliferation phase can last from weeks to months in normal cases, but with each day, due to certain cells like fibroblasts doing their jobs, the wound or injury site becomes stronger. Again, here we can either promote the proliferation phase or deter it, based on what we do during that course of therapy.
Maturation or Remodeling Phase:
The maturation or remodeling phase is the final phase in a wound or injury recovery. During this time, which can take months to even years, the tissue is further organized and strengthened. Final changes are made to structure and even blood flow to the region, which takes time. In many studies, it has been noted that even after the maturation phase has been completed, that normal tissue strength to that area of recovery is about 20% less than what it was originally. This means that with most injuries, that tissue is going to be weaker and more prone to reinjury.
Experience Improves Results:
Most horse owners, especially in the competitive realms, are used to injuries and many have their own set regimens on how to deal with the situation. Some have favorite remedies that they implement and often come with good results, but the question always remains as to 'can we do better?" In the many years that we rehabiliated off track TB's, most of the injuries we dealt with were chronic in nature, being prolonged due to improper care to begin with. Several of those horses had injuries that were just left to mend on their own while the horse was stalled for 6-12 months or even longer. In those cases, some of the original injuries did mend, but not to the degree we saw as ideal. The inflammatory process got out of control, proliferation phase even more so, then made worse with reduced or restricted movement. In the end, most of the tendon or ligament injuries became restrictive, leading to prolonged lameness.
The inflammatory phase is one that I find most critical to injury recovery. It is a phase that must be present, but it also needs to be controlled. So many things that we do can actually make the matters worse, even without knowing it. The process gets fueled, out of control and in the end, we have ongoing cellular damage, improper healing and pain. In our patients, I don't have the goal of eliminating that inflammatory phase, but more so control it, balance it and protect it from getting out of control. I want them to feel pain, as it is protective, but I want it controlled. Pain medications, such as NSAIDs, can be helpful in some cases, but personally I feel that through their overuse, they can actually work against us. I find the use of herbs to be key players in these cases. Herbs, through proper dosing, combination and frequency, can actually help us in more ways than any medications. Examples of key herbs include Curcumin or Turmeric, Boswellia, Dandelion and even Marshmallow and Aloe. These herbs all impact the inflammatory process, but don't shut it down. They regulate it, promote balance and proper function. The second thing is that most of these herbs also provide potent antioxidant capabilities, which can help to protect normal cells from further damage due to oxidative stress. Key products that I have found helpful here are the Cur-OST EQ Plus, Cur-OST EQ Pure or the Cur-OST EQ Total Support. The choice of which product is dependent on many factors specific to each case.
The second key area to success, in my experience, is proper nutrition. I have found in too many cases, that rehab patients are brought in on a laundry list of synthetic based supplements, commercial feeds and less than desireable quality hay. We have to remember that nutrients are what that body needs, not just to repair and become stronger, but to actually aid in controlling the inflammatory process. Some diets, with highly processed feeds and high synthetic loads, may prove to be more 'pro-inflammatory' in nature, fueling that process and prolonging recovery without us even given it a thought. We tend to look at a label and see list of nutrients that are 'added' to that product, and believe we are doing right by that animal. In reality, food is our main source and should be our main source of nutrient acquisition. Natural nutrients are what the body is craving and are the ideal form for digestion, assimilation and utilization. In the case when our needs outweigh our ability to provide from whole grains and high quality hays, then we resort to whole foods, in the form of herbs if needed, to further enhance those capabilities and provide nutrition. In those cases that need a natural nutrient boost, we will often use either the Cur-OST EQ Nourish or the Cur-OST EQ Rejuvenate formulas.
One final key to success that I have found in most injuries is through promoting balance and strength in the immune response. The immune system is needed to aid in removal of invading organisms such as bacteria, but also is vital to removing dead tissue so that the proliferation phase can proceed. If the immune system is compromised, due to a variety of factors, we may have a reduced ability to recover. In almost all cases, I will use the Cur-OST EQ Immune formula daily for 1-3 months to help support that healthy immune response. It can make all the difference in many cases.
Taking the different phases of injury healing into consideration, as well as different means of promoting and controlling those phases, we have had great success in recovery in most of our cases. In our experience, tendon injuries often respond quickly and are back in light ground work within 2 weeks, moving forward quickly with continued support, with most not even being confined outside of normal parameters. I do believe that time is needed for most injuries, but am not a fan of using a box stall as the means of injury management. Confinement and turning a blind eye to an injury is often one of the main reasons as to why we continue to contend with these problems. If we turn our attention to the process, control the process and provide for the body properly, recovery can often be quickly gained.
Now...if we could just use these approaches from a preventative standpoint, we may actually be able to reduce injury occurrence. Most injuries are tied in with overstress of a certain structure, but that act of overstress is an inflammatory reaction. The more controlled that inflammatory response, the more balanced it is and the better the plane of nutrition for that animal, then the stronger the tissues and less prone to injury they will become.
Author: Tom Schell, D.V.M., CVCH, CHN