A small-animal orthopedic veterinarian once told me, "The athlete that heals slowly heals best." In other words, although some physical therapy might be recommended as the body heals, the body’s soft and hard tissues need to recover wholly from the damage they suffered before undergoing the extra stress of training and the physical demands of building up, bulking up, or speeding up. Asking too much of an out-of-condition body on the mend risks delayed recovery, possible setbacks, and sometimes permanent damage.
While that wisdom applies to the canine, equine, and human athlete undergoing rehabilitation, it’s also relevant to the body that’s completed its recovery or rehabilitation and now, after a period of being laid-up, is headed back into a reconditioning program.
Explains Nat White, DVM, MS, Dipl. ACVS, Theodora Ayer Randolph Professor of Surgery, Marion duPont Scott Equine Medical Center, Virginia-Maryland Regional College of Veterinary Medicine, "We humans know that if, for example, we were exercising by running five miles a day, became injured, were laid off for two months, and then, after not running for two months, came back and tried to run five miles, we would be slower, we’d probably ache afterwards, and we’d be out of breath. The reason is our body has been de-conditioned. Basically, the body is not used to doing that exercise anymore, so all of these structures that we used to exercise underwent changes and adapted to the lesser stress, lesser speed, and lesser endurance.
"In the same light with the horse that doesn’t do anything or is laid-up, its muscles, tendons, joints, and heart all get out of shape.
"Consequently, when trying to run the five miles you did two months ago, you have to undergo training to recondition and to bring those structures back to where they need to be to hold up for that five mile race or exercise."
While the need to recondition a horse returning to work after being laid-up is an accepted part of veterinary management, how that reconditioning occurs is less universal in its approach. Reconditioning is still part science, part art. For sure, some generalities apply: Start slowly; progress gradually. Beyond that, reconditioning the post-laid-up horse becomes a matter of personal belief and preference. Following are several views on reconditioning athletic horses after injury. The regimen used for your horse should be decided with input from the attending veterinarian, who is the one most familiar with the injuries your horse has suffered and possible complications.
Sooner Better Than Later
Carol Gillis, DVM, PhD (equine tendon pathobiology), is an equine ultrasound specialist in California. She advocates gradual, controlled conditioning exercises that often begin during the rehabilitation process. She recommends stall rest combined with hand-walking, rather than starting exercise after rehabilitation is complete.
In the case of a tendon/ligament rehabilitation/reconditioning program, Gillis usually recommends a basic regimen consisting of gradual advances. Before moving on to each new step, you should have your veterinarian first perform an ultrasound to check for inflammation and evaluate healing. The reconditioning program consists of the following steps:
- Step one. Two months of stall rest along with 20 minutes of hand or hot walker exercise each day, increasing to one hour per day over 60 days.
- Step two. Two months of riding at a walk, ponying, or walking on a hot walker with weight on the back (heavy Western saddle). Begin at 20 minutes, increasing to 45-60 minutes per day over 60 days.
- Step three. Trotting five minutes each day. Increase trotting by five-minute increments every two weeks for 60 days.
- Step four. Cantering for five minutes every day. Increase canter exercises in five-minute increments every two weeks for 60 days.
- Step five. Full flat work for 60 days.
- Step six. Full training—i.e., jumping, working at racing speed—for 60 days.
- Step seven. Reconditioning should be complete with the horse ready to compete.
Marnye Elliott, director of communications for the National Hunter/Jumper Council, has bred, trained, and shown a number of hunter ponies to national American Horse Shows Association championships. She is a follower of Gillis’ techniques. Under Gillis’ guidance, Elliott successfully has rehabilitated and reconditioned three of her own horses from suspensory problems.
"We aggressively used ultrasound to monitor the healing rate and the development of fibers and the fiber pattern in the injured area," Elliott explains. "Before ultrasound, it was a best guess for soft tissue tears. The protocol was lay-up for six to eight weeks, then turnout for six months, then bring the horse back. If it made it, great. If not, bummer!"
This older method of reconditioning not only took longer, Elliott states, but often the horse would experience a setback as it approached full use. "The ultrasound helps you back off," Elliott says. "Often, the fiber pattern has not gotten dense enough to hold up to full or normal use. By backing off and doing more long and slow weight-bearing work, you can build up the fiber pattern and get back to normal."
According to Gillis, conditioning techniques likely won’t vary due to the horse’s age. "Horses seem to heal at similar rates during the age range usually associated with athletic use, that is, four to 16 years," she states. "However, very young horses (less than two years) or aged horses heal faster or slower, respectively."
Gillis recommends that reconditioning exercises mimic, when possible, the training/fitness exercises typical for a specific discipline. "For example, racehorses will do all walking exercise on a hot walker or being ponied. It is important to regard the rehabilitation program as training/fitness as well and to continue the horse’s education during the time period."
Additionally, treadmill exercise or Aquatread is helpful, as is therapeutic ultrasound for muscle injury treatments. "It is a challenge to locate a local leasing company for therapeutic ultrasound," Gillis says, "but worthwhile for a month of initial therapy for muscle injury."
Drug therapy usually is restricted to the rehabilitation rather than the reconditioning phase. "Initial drug therapy for a musculoskeletal injury includes the use of NSAIDs (non-steroidal anti-inflammatory drugs) to reduce pain, swelling, and excessive inflammation, which can cause further damage," Gillis says. She generally prefers a three-week course of phenylbutazone for treating tendon or ligament injury inflammation. Initial cold therapy during the first week post-injury also is very helpful in reducing inflammation. She adds, "If a synovial structure, such as a tendon sheath or a joint is also involved, a course of intramuscular Adequan (polysulfated glycosaminoglycan) injections is helpful.
"For moderately severe to severe tendon or ligament damage, a series of Bapten injections improves final tendon healing quality through improved fiber alignment, allowing equine athletes to have a better prognosis for return to full work."
Take care when rehabilitating an injured limb to recognize and treat lameness in other limbs to ensure even loading during rehabilitation.
Vitamin C supplementation also might be recommended. "There is some evidence that additional vitamin C in the diet of stressed, injured, or ill horses can aid in healing of musculoskeletal injury," said Gillis.
To assess progress in conditioning, Gillis suggests clinical examination and diagnostic imaging—radiographs for hard tissues and ultrasound for soft tissues—when applicable.
Finally, Gillis counsels that fatigue during training or competition is a primary cause of injury. "This kind of rehabilitation/reconditioning program is intended to produce an athlete which is more fit than prior to the injury."
Act Naturally, Quickly
"Exercise probably is one of the most important elements of rehabilitation," declares Joyce Harman, DVM, MRCVS, a certified equine acupuncturist and chiropractor and owner of Harmany Equine Clinic in Virginia. Harman, president of the American Holistic Veterinary Medical Association, believes minor exercise generally should be introduced during the rehabilitation phase. "In the horse world, we get very caught up in making everything rest," she explains. "Stick him in the stall, come back in a month or two, and hope he is better.
"But if you look at human physical therapy, they actually have machines that will start a person in physical therapy on the surgery table or immediately post-surgery, particularly for knees. In the high-tech world of sports injury where they’re trying to get the players back quickly, they start motion rehabilitation very, very early in humans, and we can do the same thing in horses, in most cases." She says most horses on the mend can benefit from having either their joints or injured limbs stretched while in the stall, or twice-daily hand-walking for 10 minutes, with increases as they begin to make further recovery.
For the rehabilitated but unconditioned horse, Harman begins with five minutes of hand-walking. "Rule-of-thumb for the out-of-condition horse or the horse that’s been injured is to add about five minutes to the exercise program every three or four days. For the horse that has literally done nothing for six months, five minutes two or three times a day of walking is plenty for the first few days! If you add too much, it very often shows up the next day or second day, and the horse will seem a bit worse or very tired. Then you have to go back down to your previous level. For horses that are somewhat fit, you may add five minutes a day, but add part of that doing some trotting."
As the horse progresses, interval training should be introduced. "Start out with three sessions of 30 to 60 seconds at the trot, with a walk in between. Three short trots are less stressful than one long trot. As the horse gets fitter, you can canter with a trot in between."
Harman generally does not recommend putting a horse which was injured on the longe-line to recondition it because usually it is worked in smaller circles on the longe (and sometimes too long in one direction). She feels that places too much torque on the inside legs. Instead, she recommends reconditioning by walking the horse down a trail or walking or trotting around the ring in a big circle.
A horse which was fit prior to lay-up and was only off for two months or less can move fairly quickly back into its training program—about three to four weeks—depending upon the seriousness of the injury, completeness of healing, and level of work. Older horses, unfit horses prior to injury, and horses off for six months or more will need to advance more slowly, as they will have lost more muscle tone as well as strength in the tendons and ligaments.
Turnout, where a rehabilitated but unconditioned horse can self-exercise, also is beneficial. "I like to get them turned out as soon as possible, because the faster the horse can get into a full day of turnout, the easier your job is going to be," Harman states. "For some horses, that means sedating them, sometimes fairly heavily, so they don’t get crazy in their first week or 10 days out and injure themselves because their muscles aren’t fit and they’re doing something strenuous."
She recommends a two- or three-hour turnout under a drug such as acepromazine. "That takes a couple of hours to wear off, and I want the horses to be out long enough that they have woken up and realized they are outside, but are relaxed about it. If they start to run or do anything silly, I bring them back in." She warns that if grass is lush and the horse has not been on grass for a while, then turnout time should be reduced until the horse becomes accustomed to being out on grass.
To help in reconditioning, Harman also might recommend the addition of neutraceuticals, alternative remedies, and alternative therapies:
"Neutraceuticals are very effective in the healing process and, depending on the injury, make the healing progress faster." For musculo-skeletal injuries, Harman favors glucosamine to promote healthier joint fluids. She also uses a lot of vitamin C for collagen healing and to help the immune system—especially important for horses laid-up due to illness.
Harman feels that various specific herbal products and homeopathic remedies might increase circulation to the joints, reduce inflammation, or improve healing from infections or illness.
Chiropractic and acupuncture, used separately or together, are particularly beneficial for the horse that is stiff from extended stall rest, she says. "Used at the beginning of a rehabilitation program, they will help get the muscles, tendons, and ligaments working, and make sure they are pain-free so the horse can start working correctly," Harman states. "Chiropractic is very good at loosening up stiffness in the spine. Acupuncture can be used for different conditions, including musculo-skeletal injuries, horses that are colicking, or for boosting the immune system."
Magnetic therapy is a useful but widely misunderstood therapy, Harman says. Most magnets are bipolar, meaning they have both a north- and south-seeking pole on the same side of the magnet. But the north-seeking side of the magnet stimulates healing of chronic conditions while the south-seeking side of the magnet helps acute, inflammatory conditions; using a bipolar magnet might deaden pain, but will do nothing to help and can even hinder the healing process.
"Use a regular magnet that has all north on one side and all south on the other," Harman advises. "You can tell by using a compass." The magnet can be taped or wrapped to the body or sewn into fabric and affixed to the body. "Leave the magnet on for only 30 to 60 minutes one to two times a day, as the body can adapt to it; once the body has adapted, the magnet will not be be effective and may be detrimental."
A horse that is progressing in its reconditioning program should look less tired after exercise sessions and should start to build healthy muscles. Beware of hard muscles, which indicate tightness, spasm, or pain due to too much or incorrect work. "When the horse can do a session of work equivalent to what he was doing before, and he bounces right back from it," says Harman, "then the horse is ready to go into its normal training routine."
Rehabilitate, Then Recondition
Ben Martin, VMD, Dipl. ACVS, and assistant professor of sports medicine at New Bolton Center, University of Pennsylvania, generally prefers to see a horse make a full recovery prior to starting in a reconditioning program. "Whatever the injury or illness happens to be—bowed tendon, bad heart, surgery—the process of recuperation should be accomplished before the horse begins the process of getting physically fit," he says.
Reconditioning begins with self-exercise via turnout in a small paddock, then turnout in a big paddock. Martin opts for graduated turn-outs in order to minimize risk of injury. "Horses like to run around," he says. "If you take a horse that’s been locked up in a stall for eight weeks and put him into a big paddock, the first thing he’s going to do is buck and wheel and run around like a maniac! So we start them in a small area where they are less likely to hurt themselves."
After the horse has been allowed out in a big paddock for about four weeks and everything has healed, he can start a walking/trotting reconditioning program. "Usually, I have the horse walking five minutes and trotting five minutes each day for a week. The second week he does 10 minutes a day and so on, until he’s up to about 30 minutes a day of walking and trotting. This is a good, basic routine to get any horse of any discipline relatively fit in 60 days."
Swimming also is excellent for improving cardiovascular function.
Depending upon the problem from which the horse is recovering, Martin might use a Holter monitor (which measures heart rhythm), ultrasound, nuclear scintigraphy, or radiographs to monitor the horse four to six weeks after it begins its exercise program.
From there, the horse can move into its training program. "About four months of reconditioning is kind of a ballpark figure for a horse that’s ready to do some concentrated exercise such as racing or competing on a cross-country course," says Martin.
Sometimes drugs are part of the rehabilitation/reconditioning program. "Most of the drugs we recommend are pharmaceuticals," Martin says. "Commonly, phenylbutazone for inflammation, Adequan or Legend (hyalur-onate sodium) for anti-inflammatory properties and improvement of synovial fluid in the joint. The nutraceuticals I most commonly recommend for middle-aged to older horses coming back from an injury or lameness are Cosequin and generic chondroitin sulfate and/or glucosamine (the major ingredients in Cosequin)."
Martin says there are a few ways to assess a horse’s progress. "One is the general, overall appearance of the horse. Second is how quickly the horse recovers from exercise—the fitter he gets, the quicker he recovers. You can also tell by how much the horse is sweating or how they’re breathing." Excessive sweating or a high respiratory rate could be an indication of too much stress and exercise. Some people use heart monitors to record how fast the horse’s heart is beating. "But basically, you can tell a horse is becoming conditioned when it starts going from being a blubberball to something more muscular."
Basics Are Best
Rehabilitation and reconditioning techniques vary according to the injury or illness and how the horse is used, says White of Virginia. "For a racehorse with a small, simple chip fracture in one of its joints, we’ll remove the chip fracture surgically, may recommend four to eight weeks of rest, followed by some light exercise for a month, then regular training. Initial exercise usually consists of trotting or light galloping. In this case, the tendons and bones usually don’t require as much reconditioning as the heart and lungs because they had been previously conditioned and have not lost much conditioning during the post-operative lay-up."
While ultrasound is an excellent way to measure the healing progress for tendon injuries, measuring heart rate at a constant speed is a good way to assess the conditioning of the cardiovascular system. "As a horse is conditioned, going at the same speed, the heart rate will become lower because it doesn’t take as much effort to sustain that speed," White says. "But this only works in hard-working horses like racehorses, and you have to monitor the heart rate during exercise."
Other than those tools, handlers must rely on their own ability to judge muscle fitness and how easily the horse is performing its work. "Basically, the trainer works the horse, and when the horse can do what the trainer wants, it suggests the horse is fit," states White. "Seriously, there is no simple way I know of where you can take some measurement and say the horse is ready to work. This is an area where people have learned how to condition horses, but there is little science behind it. We really need more research to see if we can't come up with ways to measure conditioning so we can tell if we're going too fast or too slow."
About the Author
Marcia King is an award-winning freelance writer based in Ohio who specializes in equine, canine, and feline veterinary topics. She's schooled in hunt seat, dressage, and Western pleasure.
POLL: Rehabbing the Injured Horse