SPORTS MEDICINE, LAMENESS, AND REHABILITATION Ultimately, there are no studies comparing the rest
and rehabilitation protocols. This author typically employs hand walking (20minutes daily) throughout the initial treatment period (;4weeks), followed by increasing amounts of walking under saddle, increasing by 5minutes of walk per week. Once the horse has achieved at least 30minutes of walking under saddle, trot is introduced in 2.5- to 5-minute intervals per week, depending on the severity, with canter being added only once the horse has reached 20minutes of trot work. Clients are generally advised that the horse will not return to full work for at least 6months and,in some cases,up to ayear.Other con- siderations for the controlled exercise programinclude working on level, flat, consistent surfaces, with the amount of exercise decreased by ;25% if the footing conditions are different than what the horse is accus- tomed to. For example, for horses that are walking for 30minutes on firm footing but are then abruptly required to walk in deeper sand footing, it may be ad- visable to decrease walking to 22 to 25minutes until the horse reconditions to the different footing over severalweeks. There are many other techniques that are oft-
en incorporated into a PSD rehabilitation plan. Unfortunately, many therapeutic modalities are mar- keted directly to the owner, often with unsubstanti- ated claims. However, two recent studies have shown significant improvement in horses with suspensory branch lesions that were treated with high-power laser (once daily for 2 to 4weeks).32,33 If a laser unit is available to the owner, the author prescribes its use daily in acute cases or, in chronic cases, once daily for 3days and then 3 times per week for 6weeks. Simple, inexpensive techniques should also not be overlooked. Walking over ground poles, for example, can be employed later in the under-saddle walking portion of the program to increase proprioception and begin to expose the suspensory ligament to varied range of motion and forces. Proprioceptive balance pads (which may be more appropriate after resolution of acute injury) and core strengthening exercises are incorpo- rated into many rehabilitation programs though are not necessarily specificto PSD.
3. Conclusion
Proximal suspensory disease is a complicated and complex disease that involves the proximal aspect of the suspensory ligament, its osseous origin, the DBLPaN/DBLPN, and/or the connective fascia. The wide range of tissue types and pathology involved in PSD is likely to explain the wide variety of treat- ments that are employed to manage the disease. As studies demonstrate, hindlimb PSD is harder to manage and carries a poorer long-term prognosis than forelimb PSD. However, with the combination of shockwave, biologic therapies, systemic and topical NSAIDs, bisphosphonates, shoeing, and rehabilita- tion considerations, most cases can be successfully managed without surgical intervention. However,
302 2022 / Vol. 68 / AAEP PROCEEDINGS
surgery carries a good prognosis that is at least equivalent to management with shockwave and/or biologics and is also a valid treatment option. The author has managed hundreds of cases of PSD, mostly in English performance horses, with a success rate similar to those reported in the literature, which underscores the variety of ways that PSD can be managed in performance horses.
Acknowledgments
Declaration of Ethics The Author has adhered to the Principles of Veteri- naryMedical Ethics of theAVMA.
Conflict of Interest
The Author has indirect financial interest in a com- mercial stemcell company.
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3. Boening KJ, Loffeld S, Weitkamp K, et al. Radial extracor- poreal shock wave therapy for chronic insertion desmopathy of the proximal suspensory ligament, in
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4. Crowe OM, Dyson SJ, Wright IM, et al. Treatment of chronic or recurrent proximal suspensory desmitis using ra- dial pressure wave therapy in the horse. Equine Vet J 2004;36:313–316.
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6. Loffeld S, Boening KJ, Weitkamp K, et al. Radiale extrakor- porale Stoßwellentherapie bei Pferden mit chronischer Insertionsdesmopathie am Fesselträgerursprung – Eine kontrollierte Studie. Pferdeheilkunde 2002;18:147–154.
7. Guinta K, Donnell JR, Donnell AD, et al. Prospective randomized comparison of platelet rich plasma to extracor- poreal shockwave therapy for treatment of proximal suspen- sory pain in Western Performance horses. Res Vet Sci 2020;126:38–44.
8. Seabaugh KA, Thoresen M, Giguère S. Extracorporeal shockwave therapy increases growth factor release from equine platelet-rich plasma in vitro. Front Vet Sci 2017;4:205.
9. Herthel D. Enhanced suspensory ligament healing in 100 horses by stem cell and other bone marrow components, in Proceedings. Am Assoc Equine Pract 2001;47:319–321.
10. Hall MS, Vasey JR, Russell JW, et al. Use of ultrasound- guided autologous bone marrow transfer for treatment of suspensory ligament desmitis in 30 race horses (2003-2010). Aust Vet J 2013;91:102–107.
11. Beerts C, Suls M, Broeckx SY, et al. Tenogenically induced allogenic peripheral blood mesenchymal stem cells in allo- genic platelet-rich plasma: 2-year follow-up after tendon or ligament treatment in horses. Front Vet Sci 2017;4:158.
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