If your horse has suffered a joint injury, give them ample recovery time before returning to competition. | iStockIts a joint. Quite literally, that means its a place in the horses body thats joining together a variety of structuresnamely bones, ligaments, tendons, synovial membranes, and even skin.For this reason, joint injuries in horses can be among the most complex sites to rehabilitate, because they involve so many kinds of structures.So, once your horse has sustained a joint injury, where do you start the process of getting back to good joint health? Weve asked the experts about this complex topic and came up with the following checklist for optimal joint healing.Get an Accurate DiagnosisFirst things first, good joint healing requires an accurate diagnosis, says Janine Wilson, DVM, Dipl. ACVSM, a rehabilitation resident, sports medicine veterinarian, and official veterinarian for the Fdration Equestre Internationale (FEI) at Oregon Equine, in Damascus.Wilson emphasizes the importance of basing rehabilitation programs on an accurate diagnosis: We need to know what tissues are involved and the degree of injury so a specific treatment and rehabilitation program can be developed for the horse.Tissue healing follows a general pattern; however, the timeline for healing varies by tissue type. Bones, for example, heal much faster than tendons and ligaments, Wilson says. Depending on the extent of the joint injury, several structures can be involved, making the rehabilitation program more complex.To arrive at an accurate diagnosis, veterinarians need to conduct a thorough clinical exam, combined with an initial culture (if indicated) and imaging such as X rays and ultrasound. Depending on the injurys extent, the veterinarian might refer the horse for magnetic resonance imaging (MRI), computed tomography (CT) scans, arthroscopy, or surgery, Wilson says.Recognize that Horses Different Joint Structures Have Different Healing TimesWilson says skin takes a full year to reach 70% of its original strength. This is especially true over limb joints, where skin is notoriously slow to heal due to increased motion and tension on the healing tissue. The skin over the joint is the initial protective barrier for the joint, she says. Wounds over a joint, even partial-thickness skin scrapes, can result in a joint infection or joint injury and need to be evaluated by a veterinarian. Bone healing depends on the injury. A nondisplaced fracture not requiring surgical intervention or a surgically stabilized fracture can have different healing times, says Wilson. Surgical fixation of fractures will help stabilize them and improve the healing. While it can take three or more weeks for bone to become structurally stable, it takes three or more months for bones to regain their strength.For muscles, return to full function generally takes at least six weeks, butagainthat depends on the injury. Studies of complete muscle lacerations in other species have shown muscles can return to 50% of their tensile strengththe maximum force a tissue can withstand without rupturingand about 80% of normal contraction strength in around 12 weeks, says Wilson. Although muscles might seemhealthy, they might not be fully healed. Just because the muscle is functioning doesnt mean its completely healed and strong yet, she says.Tendons, meanwhile, only reach 79% of their original strength after a year or more, says Wilson. And for ligaments the tensile strength is only at 50 to 70% a year after injury. Cartilage healing is limited because it has no direct blood, nerve, or lymphatic supply. There is no direct blood supply to deliver healing factors to cartilage, says Wilson. In a superficial cartilage wound, only 20% of normal type II collagen is present after one year of healing, meaning repair tissue is fibrous and inferior to the original cartilage. Full-thickness cartilage lesions or surgical debridement to the subchondral bone can provide direct blood flow to the injured cartilage and improve healing.Know the Timeline for Different Healing PhasesOver Horse JointsTo create a successful rehabilitation plan, first consider the type of treatment and exercise level necessary for each stage of healing. Owners and veterinarians should consider the horses health and environment and adjust the rehabilitation program depending on the horses response. It is important to remember the timeline for the three phases of healing is a guideline, and many factors can affect it, including the environment and the horses nutrition status.The first phase is the inflammatory phase, which lasts about five days. Its an acute phase where youre going to see heat, swelling, and pain, says Wilson.The second phase is proliferative, starting around six days post-injury and continuing until about Day 15. She says during the proliferative healing phase, blood vessels form, growth factors get released, fibroblasts are active, and granulation tissue formation and wound contraction begin. If a wound experiences too much movement during this healing phase, excessive granulation tissue (or proud flesh) can develop, which requires treatment for the wound to continue to heal.The third phase is remodeling, which can last 21 to 365 days, depending on the tissue type. During remodeling, maximal wound contraction occurs and, over the course of a year, the tissues tensile strength continues to increase.Collaborate with a Vet to Make a Custom Rehab Program for Your HorseDue to all the components of a joint injuryhealing phases, healing times, different tissuesits critical to get expert help developing a customized rehabilitation program based on his or her training and knowledge.There is no standard recipe, and it is wrong to always use the same protocol for all horses with joint damage, says Raquel Baccarin, DVM, PhD, FEI veterinarian, professor, and head of the Equine Internal Medicine Service at the Veterinary Hospital of the University of So Paulos School of Veterinary Medicine and Animal Science, in Brazil.For example, injuries that occur only in one type of tissue, such as within the joint capsule, or that are related exclusively to inflammation of the synovial membranea condition known as synovitismust be distinguished from those that affect multiple joint structures, Baccarin says.Also consider individual differences, she adds. Each horse will respond in its own time, Baccarin says.There isnt a one-size-fits-all rehabilitation program, Wilson adds. Plus, not all equine veterinarians have the same level of experience in different specialties. Involve an equine veterinarian who specializes in rehabilitation work, she advises.Regardless of the kind of injury and the structures involved, the goal is the same, Baccarin adds: Rehabilitation approaches incorporate methods of pain reduction, limiting adverse effects of joint inflammation, restoring joint flexibility and stability, and maximizing strength and coordination of the affected limb.Importantly, proper joint injury rehabilitation takes consistency and time, says Wilson. Owners who do not have the time to do the rehabilitation program themselves should consider a professional rehab center or the help of professionals at their home stable.Adhere to Strict Stall Rest (the Toughest Part)Our sources agree the hardest part of joint injury rehabfor owners and horses alikeis the initial stall rest.As a species that evolved to move up to 50 kilometers (about 30 miles) per day and stay near their herdmates, horses struggle with confinement alone in a stall. That can be a struggle for owners, too, says Wilson.By resisting the temptation to simply let the horse run free in the pasture, owners can improve natural joint healing.When we just turn horses out to pasture, they tend to continually strain and reinjure the area we are trying to heal, she says. If the horse keeps irritating the problem, theres no way were going to get it to heal. Stall rest with a controlled rehabilitation exercise program is needed for optimal healing.She says owners can use toys, slow feeders, and other creative approachessuch as introducing carrots frozen in a bucket of iceto keep horses on stall rest occupied. If needed, veterinarians can medicate horses to help them accept the confinement and the controlled exercise schedule.Commit to a Gradual, Customized Return to ExerciseOnce stall rest is overdepending on the horses unique situation as determined by a qualified rehabilitation veterinarianhorses can gradually return to exercise through a tightly controlled program. This can include walking and, over time, trotting in hand, followed by ridden work, Wilson says. Importantly, rehab should always start on a firm, flat surface before moving on to soft and uneven surfaces.Exercises should not only gradually strengthen the tissues but also encourage good blood flow, she explains. We have to focus on good circulation so that we get more healing components to the site of injury, Wilson says.The gradual aspect of rehab is vital, she adds, as it follows an evidence-based process of healing that will lead to optimal tissue strength and elasticity. If you do too much too soon, the tissue will reinjure, Wilson says.Most rehabilitation programs start with hand-walking on a flat, firm surface for five or 10 minutes per day, depending on the injury, and increase in increments over several weeks, she says. Other approaches can include core-strengthening exercises, such as carrot stretches and walking over poles, and working on an underwater treadmill.Long-term goals include the return to previous levels of exercise and performance and prevention or recurrence of joint injury, Baccarin explains.Resume pasture turnout only after completing the controlled exercise regimen because rambunctious play can lead to reinjury, says Wilson.Horses that struggle with a slow return to workespecially those that are highly energeticmight benefit from calming supplements, she adds.Monitor Tissue Response to the Rehab ProgramBecause each tissue in each horse is unique, its important to monitor how all are evolving during a rehab process, our sources say.Is the program too aggressive? Is it right on pace? Or is it not challenging enough? Wilson asks. We need repeat diagnostics to monitor healing and response to the rehabilitation program. Repeat diagnostic imaging or lab work can provide information about how the rehab program is working and if you need to make any adjustments, she says.Ultrasound provides the most cost-efficient monitoring solution. I typically prefer 30 to 45 days between my ultrasounds, depending on what were monitoring, she adds.Dont Cheat.Your horse looks better. And acts like he feelsbetter. In fact, you believe your competition partner is eager and ready to win that next event.And you know what? You might be right.The problem is the horse might never bring home another ribbon if joint healing isnt complete, our sources say. Yes, she might be soundfor now. And yes, he might seem enthusiastic about going back to work.But that doesnt mean your horses injured joints are ready for the challenge.To the owner, to the trainer, to the rider, the horse can look great, but were just not quite there yet, Wilson says. They might say, Oh he looks good, so lets go on to the show anyway. And thats a big mistake. It takes the time it takes to heal. Thats a physiological response, not a timeline response.Its easy to believe a horseor even a humanis better and can get back to work. But our sources say thats a bad decision in many cases, including those involving joint injuries.I think the No. 1 pitfall is lack of patience, Wilson says.Baccarin agrees. Patience, she says. The worst thing you can do is return the horse too early to exercise with a load. Tissue-healing takes time.Proceeding with training before a horse is ready can be harmful to the horse and creates more work for the owner because the whole rehab process must begin again, Wilson adds. Youve done all this work with rehab, she says. You have to be patient.Take-Home MessageHorses joints tie together multiple tissue types into one complex structure. When joints get injured, though, theyre particularly challenging to heal due to differences in tissue healing times and rehab techniques. Horse owners should seek an accurate diagnosis of specific tissue damage and ask their veterinarians to monitor lesion progression while following customized rehab programs designed by vets with equine rehab training. Though all the tissues in a joint might never reach their original strength following an injury, our sources say well-designed rehabwith owner and patient complianceshould lead to excellent athletic potential following injury.