Ligament Injuries: What the Research Says
Evidence from 22 peer-reviewed studies
What Professionals Should Know
- •MSC therapy appears clinically beneficial for horses with tendon and ligament injuries, with improved soundness and reduced lameness scores based on current evidence
- •While clinical outcomes are encouraging, tissue healing at the cellular level (mechanics, gene expression, composition) remains unproven—better standardized protocols and RCTs are needed before drawing firm conclusions about tissue repair mechanisms
- •If considering MSC therapy, standardized cell preparation and dosage protocols are critical, but currently vary widely across studies
- •PRP demonstrates therapeutic potential for tendon/ligament injuries with good safety profile, but ensure your provider uses a standardized, documented preparation method since current variation limits predictability
- •Consider combination therapy with stem cells if available, but recognize this approach still needs more rigorous clinical validation before becoming standard practice
- •Request detailed information about your PRP's platelet concentration, leukocyte levels, and activation method—these variables significantly impact outcomes but are inconsistently reported
- •While PRP and MSC treatments may help reduce reinjury rates, current evidence does not support using them to improve chances of return to performance
- •If choosing biological treatments, combining MSCs with PRP or using MSCs alone appears more effective than PRP alone for preventing re-injury
- •Study quality and bias concerns mean these findings should be interpreted cautiously; consider waiting for higher-quality evidence before investing heavily in these treatments
- •PRP shows no proven superiority over placebo or standard treatments for tendon and ligament injuries in horses based on current evidence—consider this when discussing treatment options with clients
- •While PRP is widely marketed for soft tissue injuries, clinicians should manage expectations and counsel that evidence does not yet support its routine use over conventional therapies
- •More rigorous, controlled clinical trials are needed before PRP can be recommended as a standard treatment; highlight this gap when justifying treatment choices
- •ESWT shows promise for treating tendon and ligament injuries in horses, but current evidence quality is limited by bias and weak study design—demand high-quality clinical data before adopting as standard protocol
- •Optimal energy settings, dosing, treatment frequency, and case selection criteria for different anatomical locations remain undefined—standardized protocols are needed for consistent clinical outcomes
- •Before combining ESWT with other regenerative therapies (stem cells, PRP), understand that interactions and long-term effects have not been adequately studied
- •HILT shows promise as an adjunctive therapy for tendon and ligament injuries in performance horses, demonstrating measurable pain reduction and swelling control within the treatment period
- •While HILT improved clinical signs and lesion percentage on ultrasound, it did not alter tissue echogenicity patterns, suggesting pain and oedema relief may occur independently of structural tissue changes
- •HILT combined with standard rehabilitation protocols may accelerate clinical recovery; consider as complementary tool alongside conventional management rather than as standalone treatment
- •Phasing out National Hunt flat races restricted to conditional jockeys may reduce fatality risk, as these races showed significantly higher mortality rates
- •First-time racehorses in NH flat racing are at elevated risk of fatal injury; additional pre-racing conditioning, veterinary screening, or race restrictions for debut runners should be considered
- •Bone and soft tissue injuries dominate veterinary events in this discipline; practitioners should focus surveillance and preventive strategies on these injury types
- •Stable management and horse-to-horse interactions warrant focused attention for injury prevention, as nearly half of injuries occur in the stable or during handling
- •Distal limb wounds are the most common presentation; ensure good wound management protocols and tetanus prophylaxis are routine for all traumatic cases
- •Enhanced stable design, separated feeding/turnout areas, and protective equipment during work may reduce injury incidence based on these location and mechanism data
- •High-power lasers and ESWT are safe treatment options for tendon/ligament injuries, but practitioners should recognize that clinical evidence is still developing—use cautiously as adjuncts to proven rehabilitation protocols
- •Low-level laser therapy (cold laser) is not recommended for tendon/ligament healing in horses due to insufficient therapeutic power
- •Request specific treatment protocols from vendors or practitioners offering ESWT, as standardized evidence-based dosing has not yet been established—ask about long-term outcome data before committing to treatment
- •Use foot manipulation strategically to offload tension from injured tendons or ligaments during the healing phase
- •Ground your farriery decisions in solid understanding of limb anatomy and how injuries progress—this knowledge makes the approach logical and predictable
- •Therapeutic farriery is a key part of the rehabilitation toolkit for soft tissue injuries in the distal limb when combined with appropriate rest and veterinary management
- •Consider requesting advanced imaging modalities (elastography, dual-energy CT, or diffusion-weighted MRI) when conventional ultrasound or radiographs are inconclusive, particularly for early-stage or subtle injuries
- •These quantitative techniques can provide objective data on tissue healing and functional recovery, helping inform more evidence-based decisions about return-to-work timelines
- •Elastography ultrasound may be accessible through referral centers and offers real-time assessment of tissue quality without radiation exposure
- •Biologic therapies (PRP, stem cells, scaffolds, growth factors) are advancing treatment options for tendon and ligament injuries beyond traditional rehabilitation protocols
- •Multiple biologic approaches exist with varying mechanisms; understanding which therapy suits specific injury types and stages of healing is critical for clinical decision-making
- •Gene therapy is emerging but remains largely experimental; focus your current practice on established biologics with documented clinical outcomes
- •Nearly half of eventing horses experience musculoskeletal problems; focus preventive strategies on the foot and joint structures as priority areas for your population
- •Injury prevention strategies should differ by context: educate riders about competition-related hoof/tendon injuries and training-related ligament/stifle injuries
- •Recovery time varies dramatically by injury type (2 weeks to >12 months); set realistic owner expectations and tailor rehabilitation protocols accordingly
- •Priming mesenchymal stem cells toward a tenogenic phenotype (tpMSCs) appears to enhance their ability to adhere to injured tendon and ligament tissue and promote collagen deposition, suggesting improved regenerative potential compared to unprimed cells
- •This ex vivo evidence supports the biological mechanism by which primed stem cell treatments may restore function to tendon and ligament injuries, though clinical efficacy in live horses still requires further investigation
- •Cell therapy protocols should consider pre-treatment priming strategies to optimize tenogenic differentiation and tissue integration before clinical application
- •Current biologic therapy use varies significantly among board-certified equine practitioners, suggesting ongoing debate about optimal treatment selection
- •Understanding specialist preferences and practices can help inform clinical decisions when considering biologic therapies for musculoskeletal injuries
- •This survey provides insight into which biologic approaches are most commonly adopted in real-world equine practice settings
- •Combine thorough clinical and lameness examination with ultrasonography as standard protocol for diagnosing soft tissue injuries in sport horses
- •Consider MRI when ultrasonography is inconclusive or when evaluating deep structures, especially within the hoof, to avoid missed diagnoses
- •Be aware that multiple imaging modalities (ultrasound, MRI, contrast CT) each offer complementary information—use selectively based on clinical presentation and suspected injury location
- •Combining PRP injection with ESWT post-injection may amplify growth factor release at the injury site compared to either therapy alone
- •Both standard and power probe settings effectively stimulate growth factor release from PRP, offering flexibility in clinical application
- •This in vitro evidence supports further clinical investigation of combination PRP+ESWT protocols for equine tendon and ligament injuries, though in vivo efficacy remains to be demonstrated
- •Cold therapy represents an evidence-based approach to managing acute tendon and ligament injuries in the distal limb
- •Understanding soft tissue healing phases is essential for appropriate treatment timing and modality selection in practice
- •If storing equine MSCs before therapeutic use, refrigerate at 4°C rather than keeping at room temperature to preserve cell quality and viability
- •Plan to use collected adipose tissue-derived MSCs within 24 hours; storage beyond this time compromises cell quality regardless of temperature
- •Proper storage protocols are critical for maintaining the therapeutic potential of MSCs intended for tendon, ligament, or joint treatments
- •Understanding tendon and ligament injury epidemiology and biology is critical for developing prevention and treatment strategies in racing Thoroughbreds
- •Recent research investments indicate emerging therapies and approaches that practitioners should monitor for potential clinical application
- •Early identification and management of at-risk horses may help reduce catastrophic injuries and premature retirement
- •Soft footing (sand/rubber) may reduce mechanical stress on tendons and ligaments by lowering impact forces, potentially aiding in injury prevention and lameness recovery.
- •This GRF-shoe tool enables objective quantification of how ground and shoe combinations affect comfort and propulsion efficiency—useful for identifying optimal surfaces for individual horses.
- •Understanding how forelimb joint mechanics and hoof orientation influence tendon/ligament loading can guide farriery and training decisions for high-risk activities like racing and jumping.
- •Cell-based regenerative therapy may offer new options for treating tendon and ligament injuries in horses that currently have poor healing outcomes
- •Engineered tendon tissue using a horse's own fat-derived cells combined with collagen showed promise in preclinical models and warrants further clinical investigation
- •This multi-stage research approach (meta-analysis, tissue engineering, animal models) demonstrates the pathway from concept to potential clinical application for equine soft tissue injuries
Key Research Findings
Return to soundness or performance favored MSC therapy compared to control treatments
Lameness scores improved significantly with MSC treatment
Ultrasound tissue characterization and microstructure showed positive changes with MSC therapy
No significant difference between MSC and control groups for tissue gene expression, composition, or mechanical properties
Systematic review of 22 studies found PRP improves lameness, tissue healing, and return-to-competition rates in equine tendon and ligament injuries
Significant variability exists in PRP preparation methods including platelet/leukocyte concentrations, activation techniques, and dosing protocols
Combination of PRP with mesenchymal stem cells may enhance outcomes but requires further controlled investigation
Lack of standardized PRP production and reporting protocols limits reproducibility and clinical guideline development
Meta-analysis of 17 studies found no significant increase in return to performance with PRP or MSC treatments for equine tendon and ligament injuries
MSCs alone and MSCs combined with PRP demonstrated reduced reinjury risk compared to control groups
21 studies met inclusion criteria from 764 identified studies, indicating heterogeneous literature with variable quality and high bias risk
Meta-analysis of 15 trials found no significant differences in clinical, ultrasound, histologic, or molecular outcomes between PRP and control groups for tenodesmic lesions in horses
24 trials met inclusion criteria for systematic review, but evidence quality was insufficient to support PRP efficacy
No definitive evidence that PRP enhances tendon and ligament healing in equine patients
Current literature lacks sufficient controlled trials to draw firm conclusions about PRP effectiveness for tenodesmic lesions
Evidence Base
Systematic review and meta-analysis of adult multipotent stromal/stem cell treatment for equine tendinopathy and desmopathy.
Taguchi Takashi, Lopez Mandi J, Aoun Rita et al. (2026) — Frontiers in veterinary science
Efficacy of Platelet-Rich Plasma in the Treatment of Equine Tendon and Ligament Injuries: A Systematic Review of Clinical and Experimental Studies
J. Carmona, C. López (2025) — Veterinary Sciences
Stem cells and platelet-rich plasma for the treatment of naturally occurring equine tendon and ligament injuries: a systematic review and meta-analysis.
W. M'Cloud, Kimberly E. Guzman, Char L Panek et al. (2024) — Journal of the American Veterinary Medical Association
The Use of Platelet-Rich Plasma for Treatment of Tenodesmic Lesions in Horses: A Systematic Review and Meta-Analysis of Clinical and Experimental Data.
Montano Chiara, Auletta Luigi, Greco Adelaide et al. (2021) — Animals : an open access journal from MDPI
Review of the application and efficacy of extracorporeal shockwave therapy in equine tendon and ligament injuries
Yocom A. F., Bass L. D. (2019) — Equine Veterinary Education
Effects of High Intensity Laser Therapy in the Treatment of Tendon and Ligament Injuries in Performance Horses.
Zielińska Paulina, Nicpoń Jakub, Kiełbowicz Zdzisław et al. (2020) — Animals : an open access journal from MDPI
Description of veterinary events and risk factors for fatality in National Hunt flat racing Thoroughbreds in Great Britain (2000-2013).
Allen S E, Rosanowski S M, Stirk A J et al. (2017) — Equine veterinary journal
Retrospective Analysis of Equine Traumatic Injury: Patterns and Insights
Zulfitri Naim Abdul Rahim, Noraniza Mohd Adzahan, Intan Shameha Abdul Razak et al. (2025) — Pertanika Journal of Tropical Agricultural Science
Adjunct Therapies for Tendon/Ligament Healing
Pluim Mathilde, Reynolds Angela, McClure Scott (2025) — Veterinary Clinics of North America: Equine Practice
Current Practices and Considerations in Therapeutic Farriery for Equine Tendon and Ligament Injuries.
Beasley (2025) — The Veterinary clinics of North America. Equine practice
Current and Emerging Quantitative Imaging Modalities for Diagnosing and Monitoring Equine Tendon and Ligament Injuries.
R. Urion, Meghann Lustgarten, E. Hostnik (2025) — The Veterinary clinics of North America. Equine practice
Current and Emerging Biologic Therapies for Equine Tendon and Ligament Injuries.
Shannon S. Connard, Lauren V. Schnabel (2025) — The Veterinary clinics of North America. Equine practice
Musculoskeletal Injury and Illness Patterns in British Eventing Horses: A Descriptive Study.
Tranquille Carolyne A, Chojnacka Kate, Murray Rachel C (2024) — Animals : an open access journal from MDPI
Assessing the functional properties of tenogenic primed mesenchymal stem cells in ex vivo equine tendon and ligament explants: A preliminary study.
Eva Depuydt, K. Chiers, L. V. Van Hecke et al. (2022) — Stem cell research
Current use of biologic therapies for musculoskeletal disease: A survey of board-certified equine specialists.
Knott Lindsay E, Fonseca-Martinez B Alexander, O'Connor Annette M et al. (2022) — Veterinary surgery : VS
Diagnosis of Soft Tissue Injury in the Sport Horse
Bubeck Kirstin A., Aarsvold Stacie (2018) — Veterinary Clinics of North America: Equine Practice
Seabaugh Kathryn A, Thoresen Merrilee, Giguère Steeve (2017) — Frontiers in veterinary science
Healing soft tissue injuries to the equine distal limb
Chapman Stella (2015) — Equine Health
Evaluation of storage conditions on equine adipose tissue-derived multipotent mesenchymal stromal cells.
Mercati Francesca, Pascucci Luisa, Curina Giovanni et al. (2014) — Veterinary journal (London, England : 1997)
Musculoskeletal disease and injury, now and in the future. Part 2: Tendon and ligament injuries.
Clegg P D (2012) — Equine veterinary journal
Show 2 more references
Development of a 3D model of the equine distal forelimb and of a GRF shoe for noninvasive determination of in vivo tendon and ligament loads and strains.
Rollot Y, Lecuyer E, Chateau H et al. (2004) — Equine veterinary journal
Regenerative Medicine for Tendon/Ligament Injuries: De Novo Equine Tendon/Ligament Neotissue Generation and Application
Takashi Taguchi (2023)