Equine Physiotherapy Case Study: 12-Year-Old Gelding with Tenosynovitis of the Deep Digital Flexor Tendon Sheath

Patient Background

Horse Name: Apollo

- Age: 12 years

- Breed: Warmblood

- Use: Dressage (Medium Level)

- Presenting Complaint: Intermittent lameness on the right forelimb, most pronounced during tight turns and lateral movements. Swelling around the palmar aspect of the fetlock was noted, with increased sensitivity to palpation.

Initial Veterinary Diagnosis

- Condition: Tenosynovitis of the Deep Digital Flexor Tendon Sheath (DDFTS).

- Diagnostic Findings:

- Ultrasonography revealed mild thickening of the tendon sheath and an increased amount of synovial fluid, indicating inflammation.

- No evidence of tears or lesions in the deep digital flexor tendon (DDFT) or the associated structures.

- Lameness was graded as 2/5 on a straight line, increasing to 3/5 on a circle.

#Veterinary Treatment Plan

- Non-steroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation.

- Local corticosteroid injection into the tendon sheath.

- A two-week rest period with hand-walking.

- Referral to physiotherapy to address biomechanical compensations and support recovery.

Role of Physiotherapy in Managing DDFTS Tenosynovitis

Initial Assessment by Physiotherapist

A comprehensive physiotherapy evaluation was conducted to identify compensatory movement patterns and secondary issues:

- Observation in Static Posture: Slight toe-pointing of the right forelimb, indicating discomfort.

- Dynamic Gait Analysis:

- Shortened stride on the right forelimb.

- Head nod during weight-bearing phases.

- Stiffness in the thoracolumbar region, likely due to compensatory tension.

- Palpation:

- Tenderness and mild swelling around the DDFT sheath area.

- Increased muscle tension in the thoracic sling and opposite hindlimb, likely from overloading.

Physiotherapy Goals

1. Manage Pain and Inflammation: Reduce discomfort and facilitate a healing environment for the tendon sheath.

2. Restore Normal Biomechanics: Encourage proper movement patterns to prevent overloading of the limb or compensatory structures.

3. Enhance Range of Motion and Strength: Maintain joint flexibility and gradually restore strength to the DDFT region and supporting musculature.

4. Prevent Recurrence: Improve Apollo’s long-term biomechanics to reduce re-injury risk.

Physiotherapy Intervention Plan

Phase 1: Acute Phase (Weeks 1–3)

Focus: Pain relief, inflammation management, and controlled movement.

- Cryotherapy: Application of cold packs for 15–20 minutes, 2–3 times daily, to reduce swelling and inflammation.

- Laser Therapy: Low-level laser therapy (LLLT) over the tendon sheath to enhance tissue healing and reduce inflammation.

- Manual Therapy:

- Gentle soft tissue massage around the fetlock and proximal areas to relieve tension without stressing the tendon.

- Myofascial release techniques on the shoulder and back to address compensatory muscle tension.

- Controlled Exercise:

- 10–15 minutes of hand-walking on firm, even ground.

- Gradual increase in duration as tolerated, avoiding uneven surfaces or tight turns.

Phase 2: Subacute Phase (Weeks 4–8)

Focus: Improving flexibility and promoting tissue re-modeling.

- Stretching: Passive range of motion (PROM) exercises for the fetlock and carpal joints to maintain flexibility.

- Ultrasound Therapy: Therapeutic ultrasound over the DDFT sheath to improve circulation and facilitate tissue repair.

- Strengthening Exercises:

- Ground poles at a walk to encourage proper limb engagement without overloading the DDFT.

- Incorporation of slow hill work to build strength and stability.

- Hydrotherapy: Use of an equine water treadmill to reduce impact forces while encouraging active movement.

Complication at Week 8:

Apollo sustained a kick to the right hindlimb while in the field, causing soft tissue bruising. This delayed recovery and required a temporary adjustment in the rehabilitation program. He was placed on box rest for five days to limit movement and allow healing. During this period:

- Foam Pad Exercises: These low-concussive stability exercises were introduced to improve proprioception and enhance weight-bearing stability in a controlled environment. Apollo stood on foam pads for short periods (1–2 minutes per limb), gradually increasing duration as tolerated.

- Carrot Stretches: Targeted stretching exercises were used to maintain thoracolumbar mobility and strengthen the multifidus muscle, which plays a key role in spinal stability.

- Light Massage: Gentle massage was performed to address any compensatory tension caused by the altered movement patterns.

After the five-day rest period, Apollo resumed the previous plan with modifications, including a slower progression of ridden work and dynamic exercises.

Phase 3: Rehabilitation and Conditioning (Weeks 9–16)

Focus: Strengthening, restoring normal gait, and preparing for return to work.

- Dynamic Mobilisation Exercises: Carrot stretches were continued to maintain spinal stability and flexibility.

- Proprioceptive Training: Balance pad exercises were extended, with Apollo now performing limb lifts and weight shifts while standing on the pads.

- Graduated Ridden Work:

- Straight-line walk and trot under saddle were reintroduced after clearance from the veterinarian.

- Lateral movements and small circles were incorporated gradually, ensuring no signs of re-injury.

Outcomes and Follow-Up

- 12-Week Reassessment:

- Despite the temporary setback, Apollo showed marked improvement in stride length, weight-bearing, and overall comfort.

- No swelling or tenderness around the DDFT sheath was noted.

- Gait returned to normal during both straight-line and circle assessments.

- Return to Work:

- Cleared for full dressage training after 16 weeks, with ongoing physiotherapy exercises integrated into his daily routine to maintain flexibility and strength.

- Long-Term Maintenance:

- Regular stretching and strengthening exercises.

- Monthly physiotherapy check-ups to monitor for compensatory issues and early signs of re-injury! - this is an important aspect to remember for managing a condition like this.

Discussion

The setback in week 8 required adaptive physiotherapy strategies to ensure continuity of care while preventing further injury. The use of foam pads for stability and carrot stretches for spinal support allowed Apollo to maintain progress even during box rest. This case highlights the importance of flexibility in rehabilitation planning and underscores how physiotherapy can address not only the primary injury but also complications during recovery.

With an integrated approach, Apollo successfully returned to work with reduced risk of recurrence, showcasing the value of tailored rehabilitation programs for equine athletes.