Effects of exercise on biomechanical properties of the superficial digital flexor tendon in foals.

OBJECTIVE: To determine the effects of exercise on biomechanical properties of the superficial digital flexor tendon (SDFT) in foals. ANIMALS: 43 Dutch Warmblood foals. PROCEDURE: From 1 week until 5 months of age, 14 foals were housed in stalls and not exercised, 14 foals were housed in stalls and exercised daily, and 15 foals were maintained at pasture. Eight foals in each group were euthanatized at 5 months, and remaining foals were housed together in a stall and paddock until euthanatized at 11 months. After euthanasia, SDFT were isolated and fit in a material testing system. Mean cross-sectional area (CSA) was measured and traction forces recorded. Normalized force at rupture (force(rup)), normalized force at 4% strain, strain at rupture, stress at 4% strain (stress(4%stain)), and stress at rupture were compared among and within groups. RESULTS: At 5 months, mean CSA and normalized force(rup) were significantly greater and stress(4%strain) significantly less in the pastured group, compared with the other groups. At 11 months, CSA and normalized force(rup) were not significantly different among groups, because force(rup) increased significantly from 5 to 11 months in the nonexercised group and decreased significantly in the pastured group. CONCLUSIONS AND CLINICAL RELEVANCE: Exercise significantly affected the biomechanical properties of the SDFT in foals. Evenly distributed moderate- and low-intensity exercise at a young age may be more effective for development of strong, flexible tendons in horses than single episodes of high-intensity exercise superimposed on stall rest. This effect may impact later susceptibility to SDFT injury.     

Control of the collagen fibril diameter in the equine superficial digital flexor tendon in horses by decorin

The distribution pattern of collagen fibril diameter in the equine superficial digital flexor tendon (SDFT) is known to differ in central and peripheral areas of some regions. This study reports the essence of collagen fibril differences among different regions of the equine SDFT by transmission electron microscopic (TEM) and high-voltage electron microscopic observations and biochemical analysis. The distribution of large collagen fibrils increased but the density of collagen fibrils decreased from the proximal metacarpal region to the distal metacarpal region. Large collagen fibrils with an irregular cross-sectional profile were found more frequently in the middle metacarpal region than in other regions. Three-dimensional reconstruction of images of irregularly shaped collagen fibrils revealed that these fibrils are formed through fusion of small collagen fibrils with large ones. The amount of decorin, which reportedly inhibits the lateral fusion of collagen fibrils, decreased in the direction of the distal metacarpal region. On the other hand, the size of decorin gradually increased in the direction of the distal metacarpal region. These results suggest that regional differences in collagen fibril distribution and density of collagen fibrils in the SDFT are due, at least in part, to fusion of collagen fibrils and the concomitant regional differences in the amount and size of decorin.     

Age-related differences in collagen crimp patterns in the superficial digital flexor tendon core region of untrained horses

Objective To measure collagen fibril crimp angles and lengths as well as collagen fibril mass-average diameters in central and peripheral regions of the superficial digital flexor tendon of wild horses, to ascertain any age-related changes in either region in the absence of imposed galloping exercise.
Design Measurements from a random cull of wild horses.
Sample population Superficial digital flexor tendon samples were taken from 23 wild horses ranging in age from two to ten years.
Procedure Horses were divided into 'young' (< 5 years, n = 10), 'middle-aged' (5 to < 10 years, n = 9) and 'old' groups (10+ years, n = 4) and the mean crimp angle, mean crimp length and collagen fibril mass-average diameter calculated for the central region, and for the peripheral region of each group. Differences between groups and regions were analysed using two-tailed t tests.
Results The crimp angle for the central region was found to decrease with age, so that in old horses it was smaller than that for the tendon periphery (P < 0.05). The crimp angle for the latter region did not alter significantly with age. Crimp period lengths and collagen fibril mass-average diameters did not show significant changes with age in either region.
Conclusion Reduction of the crimp angle in the core of the superficial digital flexor tendon occurs normally with age, as tendons of older animals would have undergone a higher number of loading cycles. It is possible that athletic training increases the frequency and/or the magnitude of high loading cycles experienced by the tendon, and may accelerate and worsen the normal load-related ageing process in the superficial digital flexor tendons of young performance horses, particularly in the central regions where lesions usually occur.     

Microdamage in the equine superficial digital flexor tendon

The forelimb superficial digital flexor tendon (SDFT) is an energy-storing tendon that is highly susceptible to injury during activities such as galloping and jumping, such that it is one of the most commonly reported causes of lameness in the performance horse. This review outlines the biomechanical and biothermal effects of strain on the SDFT and how these contribute to the accumulation of microdamage. The effect of age-related alterations on strain response and subsequent injury risk is also considered. Given that tendon is a slowly healing and poorly regenerative tissue, prompt detection of early stages of pathology in vivo and timely adaptations to training protocols are likely to have a greater outcome than advances in treatment. Early screening tools and detection protocols could subsequently be of benefit in identifying subclinical signs of degeneration during the training programme. This provides an opportunity for preventative strategies to be implemented to minimise incidences of SDFT injury and reduce recovery periods in elite performance horses. Therefore, this review will focus on the modalities available to implement early screening and prevention protocols as opposed to methods to diagnose and treat injuries.     

Luxation of the superficial digital flexor tendon in a cat

Superficial digital flexor luxation has been described in dogs, horses, and cattle. To the authors' knowledge, it has not been reported in cats. In the case of this report, monofilament nonabsorbable suture material was used to repair a laterally luxating superficial digital flexor tendon in a cat. The repair was similar to that which has been described in dogs. Whereas many etiologies of superficial tendon luxation have been proposed in dogs, trauma was believed to have contributed to the tendon luxation in this cat.     

Mechanical and functional properties of the equine superficial digital flexor tendon

The in vitro and in vivo mechanical properties of the superficial digital flexor tendon have been described. To date the focus has been on single load to failure testing, however refined in vivo methods may prove useful to evaluate the effects of treatment and exercise on tendons. During maximal exercise, the adult superficial digital flexor tendon operates close to its functional limits with a narrow biomechanical safety margin. This combined with exercise and age associated microdamage, and a limited adaptive ability may increase the risk of fatigue failure. Studies evaluating treatment regimens for tendonitis have focused on repair and regeneration and yielded varying results. It would appear that the superficial digital flexor tendon has a limited ability if any to adapt positively to exercise after maturity. In contrast, the foal's superficial digital flexor tendon may have a greater adaptive ability and may respond to an appropriate exercise regimen to produce a more functionally adapted tendon. Recent studies have shown that foals allowed free pasture exercise develop a larger, stronger, more elastic tendon compared to foals that were confined or subjected to a training program. Effects on the non-collagenous matrix appear to be responsible for these differences. In contrast, training or excess exercise may have permanent detrimental effects on the biomechanical and functional properties of the superficial digital flexor tendon in the foal. The implication is that the determination of optimum exercise intensity and timing, and the role of the non-collagenous matrix in tendon physiology in the young horse may hold the key to developing tendons more capable of resisting injury.     

Histology and ultrastructure of the developing superficial digital flexor tendon in rabbits

This study was designed to investigate the developmental changes in the superficial digital flexor tendon (SDFT) of the white New Zealand rabbit, from 5 to 7 days pre-natal to 112 days post-natal (PN), at histological and ultrastructural levels. The tendons changed from being highly cellular with 13079 ± 2538 cell/mm² and little directional organization to a longitudinally oriented, predominantly connective tissue structure with relatively few, mature tenocytes (2384 ± 365 cell/mm²). Fibrillogenesis was seen in isolated vacuoles of fibroblast cytoplasm during fetal life as well as after birth, but less frequently with increasing age. At the ultrastructural level, there was a progressive increase in the mean diameter of collagen fibrils with age throughout the population , until PN day 28. A bimodal distribution of collagen fibril size was first observed on PN day 56 while at day 112, the fibrils were fully differentiated and showed a multimodal size distribution. The development of elastic fibres preceded that of collagen fibres and accompanied progressively more marked sinusoidal crimping in collagen fibres on PN days 7 and 14. The tendons of older animals became less tightly crimped. The cells of the epi- and endotenon were less mature and relatively undifferentiated compared with the cells in the body of the tendon of the same age, which might explain their ability to initiate healing of tendon injuries in older animals. In conclusion, extensive changes were observed in tendons during growth and maturation, with diameters of collagen fibrils, tissue orientation and cellularity being the parameters affected, probably due largely to increased physical activity.     

Exercise modifies the age-related change in crimp pattern in the core region of the equine superficial digital flexor tendon

One of the current concepts with regard to equine superficial digital flexor tendonitis is that cumulative subclinical microscopic damage weakens the structure, predisposing the tendon to partial or complete rupture. This microtrauma is likely to affect the waveform or crimp of the collagen fibrils, which are the units of tensile strength. Collagen fibril crimp morphology characteristics were determined in superficial digital flexor tendons of 18 horses presented for necropsy. Horses were separated into exercised (n = 9) and non-exercised groups (n = 9), based on recent function. Five of the eight exercised horses below the age of 10 years showed a significantly lower crimp angle in the central region of the tendon in comparison with the periphery. Three of those five animals also showed a significantly lower crimp period length in the centre. No non-exercised horses in this age group showed such regional differences. Horses classified as non-exercised may have Horses classified as non-exercised may have undergone competitive galloping activity at an earlier age, implying that changes in central region crimp morphology did not occur at that time, or had reverted to normal values in the intervening period. A lower crimp angle in the core region in comparison with the periphery is abnormal in animals younger than 10 years, on the basis of previous data obtained from wild horses. It is hypothesised that imposed exercise regimens involving galloping modify the normal age-related reduction of crimp angle in the tendon core, probably as a result of the increased number of rapid high-strain cycles experienced by the collagen fibrils.     

The influence of exercise during growth on ultrasonographic parameters of the superficial digital flexor tendon of young Thoroughbred horses

REASON FOR PERFORMING STUDY: Conditioning by early training may influence the composition of certain musculoskeletal tissues, but very few data exist on its effect during growth on tendon structure and function. OBJECTIVES: To investigate whether conditioning exercise in young foals would lead to any ultrasonographically detectable damage to the superficial digital flexor tendon or an increase in cross-sectional area (CSA). METHODS: Thirty-three Thoroughbred foals reared at pasture were allocated to 2 groups: control (PASTEX) allowed exercise freely at pasture; and CONDEX, also at pasture, began conditioning exercise from mean age 21 days over 1030 m on a purpose-built oval grass track, for 5 days/week until mean age 18 months. Foals were observed daily, and underwent orthopaedic examination monthly. Ultrasonographic images of the superficial digital flexor tendon (SDFT) at the mid-metacarpal level of both forelimbs were obtained in all foals at ages 5, 8, 12, 15 and 18 months. CSA was validated (r(2) = 0.89) by determining CSA from digital photographs of the transected SDFT surface from 12 of the horses necropsied at age 17.1 months. RESULTS: here was no clinical or ultrasonographic evidence of tendonopathy in either group and the greatest increase in mean CSA in both groups occurred between age 5 and 8 months. Across all age categories, there was no significant difference in mean CSA between the left and right limbs, or colts and fillies; there was a trend towards a larger CSA in the CONDEX group (P = 0.058). CONCLUSIONS: There was no conclusive evidence for a structural adaptive hypertrophy of the SDFT, probably because the regimen was insufficiently rigorous or because spontaneous pasture exercise may induce maximal development of energy storing tendons. POTENTIAL RELEVANCE: A moderate amount of early conditioning exercise against a background of constant exercise at pasture is not harmful to the development of the flexor tendons.     

Localization of cytokines in tendinocytes of the superficial digital flexor tendon in the horse

Although inflammatory activation of cytokines have been analyzed in various tissues, there have only been a few and as-yet-inconclusive studies on cytokines in equine tendons. In this study, the localizations of 4 cytokines (IL-1alpha, IL-1beta, TNFalpha and IFNgamma) in tendinocytes of the equine superficial digital flexor tendon (SDFT) were analyzed by the use of an immunohistochemical method. In inflamed tendons positive staining for all 4 cytokines antibodies were detected in endotedinieum cells and vascular epithelial cells. In contrast, negative or trace immunoreactions were obtained in many tendinocytes in the normal tendon. The variation in cellular immune responses depending on the kind of cytokine may reflect the physiological/pathological condition of the SDFT.     

The pathobiology of exercise-induced superficial digital flexor tendon injury in Thoroughbred racehorses

Despite the high incidence of superficial digital flexor tendon (SDFT) injury in racehorses, the pathobiology of the condition is not clearly defined. The SDFT improves locomotor efficiency by storing elastic energy, but as a result it has low mechanical safety margins. As with the Achilles tendon in humans, rupture during athletic activity often follows accumulation of exercise and age-induced degenerative change that is not repaired by tenocytes. There is limited understanding of tenocyte biology and pathology, including responses to high mechanical strains and core temperatures during exercise. Unfortunately, much of the current information on SDFT pathology is derived from studies of collagenase-induced injury, which is a controversial model. Following rupture the overlapping phases of reactive inflammation, proliferation, remodelling and maturation do not necessarily reconstitute normal structure and function, resulting in long-term persistence of scar tissue and high re-injury rates. Tissue engineering approaches are likely to be applicable to SDFT lesions, but will require significant advances in cell biology research.     

Preliminary studies on the vascular anatomy of the equine superficial digital flexor tendon.

The vascular and microvascular anatomy of normal equine superficial digital flexor tendons was studied by dissection of vinyl-perfused specimens and by microangiography on high detail film. The presence of an extensive intratendinous vascular latticework was confirmed, and a 'nutrient artery' described closely associated with the accessory ligament of the superficial digital flexor tendon (proximal check ligament). Circumferential stripping of the paratenon from the tendon to eliminate afferent vessels was performed bilaterally in three horses and unilaterally in a fourth, followed by a treadmill training regimen. No resulting intratendinous lesions could be documented on gross post mortem and histological examination at three, 10, or 35 days post operatively. There was mild paratendinous proliferation in all instances. In one horse, four intratendinous ligatures were placed within the medial and lateral borders of the contralateral tendon to isolate further from its blood supply a 10 cm segment. Gross lesions at 35 days post operatively included a marked paratendinous response involving the entire 10 cm segment, and a darkened, soft focus within the core of the tendon. Histopathology and electron microscopy demonstrated focal degeneration. It was concluded that the blood supply of the normal equine superficial digital flexor tendon is primarily intratendinous, rather than paratendinous as previously thought. The lesions in one horse similar to those in naturally occurring tendinitis supported a vascular aetiology of the disease, and set the groundwork for studies aimed at the development of a clinically relevant tendinitis model.     

Quantitative effect of tenorrhaphy on intrinsic vasculature of the equine superficial digital flexor tendon

OBJECTIVE: To compare effects of the locking-loop suture pattern (LLP) and 3-loop pulley (3LP) suture pattern for tenorrhaphy on the intrinsic vasculature of the superficial digital flexor tendon (SDFT) of horses in vitro after surgery. SAMPLE POPULATION: 16 forelimbs obtained from 8 mature horses. PROCEDURE: Tenotomy and subsequent tenorrhaphy was performed in anesthetized horses. Following systemic administration of heparin, horses were euthanatized and the limbs were removed and placed under tension to load the flexor tendons. The intrinsic vasculature was then perfused with a mixture of barium sulfate and water. Four-millimeter sections of the SDFT were prepared for microangiographic analysis. Mean vessel density was calculated for each section by use of a grid consisting of 1.5-mm2 vascular assessment squares (VAS). Comparisons were made among the control, LLP and 3LP groups. RESULTS: Mean +/- SD vessel density was 3.11 +/- 0.38, 1.47 +/- 0.47, and 2.01 +/- 0.63 perfused vessels/1.5 mm2 for control, LLP and 3LP groups, respectively. Significant differences in vascular density were detected between the control and 3LP groups, control and LLP groups, and LLP and 3LP groups. CONCLUSIONS AND CLINICAL RELEVANCE: Use of the LLP and 3LP pattern has deleterious effects in vitro on the intrinsic vasculature of the SDFT. However, the 3LP pattern was less disruptive to the intrinsic vasculature, compared with the effects for the LLP. Use of the 3LP tenorrhaphy suture pattern in clinical situations may result in less damage to the intrinsic vasculature of the SDFT of horses during convalescence.     

Injuries of the calcaneal insertions of the superficial digital flexor tendon in 19 horses

Reasons for performing study: Injuries of the calcaneal insertions of the superficial digital flexor tendon and their relationship to displacement of the tendon from the calcaneus have not previously been reported. Objectives: To describe findings made on clinical cases with disruption of the calcaneal insertions of the superficial digital flexor tendon (SDFT) including observations on their role in horses with unstable subluxation of the tendon. To describe novel surgical techniques and the results of treatment. Hypotheses: Disruption of the calcaneal insertions of the SDFT is associated with lameness and distension of the calcaneal bursa. Unstable displacement of the SDFT from the calcaneus is a more complex injury than incomplete disruption of one of its calcaneal insertions. Methods: The case records and diagnostic images of horses with lesions involving the calcaneal insertions of the SDFT, which were confirmed by endoscopic evaluation of calcaneal bursa between 2005 and 2009, were reviewed. Results: Nineteen horses were identified including 7 that had unstable displacement of the tendon from the calcaneus. Following endoscopic surgery, 9 of 12 horses with stable tendons and 6 of 7 horses with unstable displaced SDFTs returned to work. Conclusion: Tearing of the calcaneal insertions of the SDFT is associated with lameness and distension of the calcaneal bursa; endoscopic removal of the torn tissue carries a good prognosis. Horses with unstable displacement of the tendon have also disruption of the tendon fibrocartilage cap. Removal of this results in stable subluxation and can return horses to athletic activity. Both lesions can be detected by preoperative ultrasonography. Potential relevance: Tearing of the calcaneal insertions of the SDFT should be included in the differential diagnoses of lame horses with distended calcaneal bursae. Tearing of the tendon fibrocartilage cap in horses with unstable displacement of the SDFT is a plausible explanation of the clinical features of the injury and explains previously unreliable results of reconstructive surgeries. Subtotal resection is a technically demanding technique but appears to offer an improved prognosis.     

Repeatability of diagnostic ultrasonography in the assessment of the equine superficial digital flexor tendon

A quantitative investigation of the variation that can occur during the course of ultrasonography of the equine superficial digital flexor tendons (SDFT) was undertaken. The aim of this investigation was to use an objective measure, namely the measurement of CSA, to quantify the variability occurring during the course of the ultrasonographic assessment of the equine SDFT. The effects of 3 variables on the CSA measurements were determined. 1) Image acquisition operator (IAc): two different operators undertaking the ultrasonographic examination; 2) image analysis operator (IAn): two different operators undertaking the calculation of CSA values from previously stored images; and 3) analytical equipment (used during CSA measurement) (IEq): the use of 2 different sets of equipment during calculation of CSA values. Tendon cross-sectional area (CSA) measurements were used as the comparative variable of 3 potential sources: interoperator, during image acquisition; interoperator, during CSA measurement; and intraoperator, when using different analytical equipment. Two operators obtained transverse ultrasonographic images from the forelimb SDFTs of 16 National Hunt (NH) Thoroughbred (TB) racehorses, each undertaking analysis of their own and the other operator's images. One operator undertook analysis of their images using 2 sets of equipment. There was no statistically significant difference in the results obtained when different operators undertook image acquisition (P>0.05). At all but the most distal level, there was no significant difference when different equipment was used during analysis (P>0.05). A significant difference (P<0.01) was reported when different operators undertook image analysis, one operator consistently returning larger measurements. Different operators undertaking different stages of an examination can result in significant variability. To reduce confounding during ultrasonographic investigations involving multiple persons, one operator should undertake image analysis, although different operators may undertake image acquisition.     

Tendonitis of the branches of insertion of the superficial digital flexor tendon in horses

Objective To describe clinical findings, ultrasonographic features and outcome of injury to the branches of insertion of the superficial digital flexor (SDF) tendon in horses.
Design Retrospective study of 14 cases.
Procedure Fourteen Thoroughbred horses with tendonitis affecting the branches of insertion of the SDF tendon were examined for lameness, location and amount of swelling, and the presence of other musculoskeletal abnormalities. The flexor tendons were assessed by ultrasonographic examination, and recommendations were made for management of the cases. Outcome was assessed by re-examination of some horses, direct communication with the owner or trainer, and examination of race records.
Results The lateral SDF branch was affected in 10 horses; the medial branch in three, and both branches in one horse. Two horses had concurrent injuries to the SDF tendon in the metacarpal region of the contralateral limb. Ultrasonographic findings included swelling of the affected SDF branch, peritendinous fluid accumulation, disruption of normal fibre alignment on sagittal scan, and variable loss of echogenicity. As healing occurred, there was return of normal echogenicity, but normal fibre alignment did not return completely and apparent adhesions formed between the affected SDF branch and adjacent structures. Seven of 10 horses which returned to their previous use were able to compete without further tendon injury. Recurrence of injury occurred in one case, and another two horses developed tendonitis in the metacarpal region. One horse was retired from racing but was able to compete at dressage without recurrence of injury. Two horses were retired for breeding without returning to training, and one horse was sold and lost to follow up but did not race.
Conclusion The prognosis is fair for return to previous use following injury to the branches of insertion of the SDF tendon in athletic horses.