Tendon Injuries: What the Research Says
Evidence from 33 peer-reviewed studies
5 Systematic Review
1 RCT
4 Cohort Study
3 Case Report
17 Expert Opinion
3 Thesis
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
- •Fractures predominate in Thoroughbreds on dirt tracks while tendon injuries are common in Arabians on both surfaces—adjust training intensity and recovery protocols by breed and track type
- •The carpal joint and distal forelimb structures are injury hotspots during racing; prioritize preventive conditioning and early detection of lameness in these areas
- •Summer months (June-September) show peak injury rates—intensify track maintenance, monitor footing conditions closely, and consider adjusted training schedules during dry periods
- •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
- •Trainers should be aware that fracture and tendon injury rates vary substantially between yards, suggesting management and training practices significantly influence injury risk
- •Younger horses and those transitioning from store backgrounds require heightened monitoring for tendon and ligament injuries, particularly during racecourse activity
- •The predominance of superficial digital flexor injuries (89% of tendon/ligament cases) should inform conditioning programmes, farriery support, and early detection protocols in training yards
- •Trailing forelimbs experience substantially greater tendon loading during jump landings, suggesting this limb may be at higher risk for flexor tendon injury in jumping horses
- •The asymmetrical loading pattern between leading and trailing forelimbs should inform conditioning programs and injury prevention strategies tailored to each limb's specific demands
- •Monitor for unexpected extensor tendon stress in leading forelimbs during jumping, as this atypical loading pattern may contribute to injuries not typically associated with jumping
- •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
- •Ultrasonography remains essential for routine diagnosis of tendon sheath disease, joint effusion, and abscess formation in lameness cases
- •Elastography adds diagnostic value by assessing tendon elasticity and stiffness changes, helping differentiate tissue quality beyond structural appearance alone
- •Integrating elastography into your diagnostic protocol can improve assessment of healing tissue and guide rehabilitation decisions for soft tissue injuries
- •This model provides quantitative baseline data on digital flexor muscle force capacity that can inform treatment planning for flexor tendon injuries and deformities
- •The differential innervation patterns of SDF and DDF muscles may help explain functional differences in flexor anatomy and should be considered when evaluating flexor injuries
- •Understanding peak isometric forces in these muscles provides a foundation for developing more targeted therapeutic interventions for common flexor pathologies
- •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
- •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
- •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
- •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
- •MSC therapy adoption among Flemish practitioners is at ~50%, indicating growing but not yet mainstream acceptance; cost and complexity remain significant implementation barriers
- •Conventional therapy remains preferred despite practitioner dissatisfaction, suggesting practitioners need more robust evidence and practical protocols before switching to biological treatments
- •If considering MSC therapy, seek practitioners with established protocols and strong evidence base, as availability of standardized guidelines is currently limited
- •Understanding tendon mechanobiology and how mechanical forces influence healing can guide more effective rehabilitation protocols for tendon injuries in practice
- •Different tendon types (energy-storing vs. positional) require tailored treatment strategies based on their distinct biomechanical properties
- •Tissue engineering and controlled mechanical loading represent emerging alternatives that may improve outcomes beyond current standard treatments for problematic tendon cases
- •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
- •Regenerative medicine options (cell-based and cell-free therapies) are available for equine tendon and joint injuries, but treatment results vary due to lack of standardized protocols
- •Traditional repair mechanisms frequently fail to restore full function; regenerative approaches aim to stimulate endogenous healing but require further research validation
- •Discuss realistic expectations with owners—while promising, regenerative therapies do not yet guarantee complete functional recovery or prevent chronic degenerative progression in all cases
- •Contrast therapy shows promise for equine tendon rehabilitation based on human protocols, but evidence-based guidelines for horses are needed before routine implementation
- •Understanding how equine distal limb tissues respond to alternating temperature changes could optimize rehabilitation protocols and potentially improve recovery outcomes
- •Current evidence suggests considering contrast therapy as a complementary approach to traditional cryotherapy-only or heating-only protocols, pending further equine-specific research
- •Understanding how tendon boots and bandages affect temperature during exercise can inform selection of appropriate protective equipment for competition
- •Thermal management during work may influence tendon health and injury risk in competition horses
- •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
- •MSC therapy for equine tendon disease shows promise but remains largely experimental; clinicians should maintain realistic expectations and inform clients that this is not yet a proven standard treatment
- •The significant prevalence of superficial digital flexor tendonitis in horses means this species is driving research forward, but benefits may take years to materialize into clinical practice
- •Be cautious of claims of 'functional tissue engineering' success until peer-reviewed evidence demonstrates superior outcomes compared to conventional rehabilitation protocols
- •Intrathecal and intraneural local anaesthetic injections may compromise tenocyte viability and potentially reduce efficacy of associated therapies in horses with tendon conditions.
- •Consider using platelet rich plasma adjunctively with local anaesthetic injections to mitigate cytotoxic effects on tendon tissue.
- •Exercise caution when using local anaesthetics for lameness examinations or pain management in horses with tendon involvement, particularly with higher concentrations.
- •Adipose-derived MSC injections appear to stimulate tenogenic gene expression in tendon cells in vitro, suggesting potential molecular benefits for tendon repair therapy
- •The decreased type I collagen expression warrants further investigation before assuming clinical benefit, as collagen quality and quantity are critical for functional tendon healing
- •In vitro results are promising but long-term efficacy and clinical outcomes in vivo remain to be determined before relying on MSC therapy as primary treatment
- •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
Systematic Review
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
Systematic Review
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
Systematic Review
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
Systematic Review
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
Systematic Review
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
RCT
Distribution of race and training-related musculoskeletal injuries by track and location in Thoroughbred and Arabian racehorses.
Yildirim İsmail Gökçe, Karaarslan Solmaz, Erkan Atacan (2025) — Equine veterinary journal
Cohort Study
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
Cohort Study
Descriptive epidemiology of fracture, tendon and suspensory ligament injuries in National Hunt racehorses in training.
Ely E R, Avella C S, Price J S et al. (2009) — Equine veterinary journal
Cohort Study
Joint moments in the distal forelimbs of jumping horses during landing.
Meershoek L S, Roepstorff L, Schamhardt H C et al. (2001) — Equine veterinary journal
Cohort Study
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
Case Report
Diagnostic Approaches to Tendon, Ligament and Joint Affections in Equine with Special Reference to Tendon Elastography
Sheikh Mohd Yaseen Jani, S. K. Mahajan, J. Mohindroo (2020) — Indian Journal of Animal Research
Case Report
An in vivo equine forelimb model for short-term recording of peak isometric force in the superficial and deep digital flexor muscles.
Zarucco Laura, Swanstrom Michael D, Driessen Bernd et al. (2003) — Veterinary surgery : VS
Case Report
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
Expert Opinion
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
Expert Opinion
Current Practices and Considerations in Therapeutic Farriery for Equine Tendon and Ligament Injuries.
Beasley (2025) — The Veterinary clinics of North America. Equine practice
Expert Opinion
Adjunct Therapies for Tendon/Ligament Healing
Pluim Mathilde, Reynolds Angela, McClure Scott (2025) — Veterinary Clinics of North America: Equine Practice
Expert Opinion
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
Expert Opinion
A survey on Flemish veterinary practitioners’ experience with stem cell therapy to treat equine tendon injuries
S. Holemans, M. Meeremans, M. Oosterlinck et al. (2023) — Vlaams Diergeneeskundig Tijdschrift
Expert Opinion
Equine tendon mechanical behaviour: Prospects for repair and regeneration applications.
Shojaee (2023) — Veterinary medicine and science
Expert Opinion
Show 13 more references
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
Expert Opinion
Regenerative Medicine for Equine Musculoskeletal Diseases.
Ribitsch Iris, Oreff Gil Lola, Jenner Florien (2021) — Animals : an open access journal from MDPI
Expert Opinion
Contrast therapy: Tissue heating and cooling properties within the equine distal limb.
Haussler Kevin K, Wilde Shana R, Davis Michael S et al. (2021) — Equine veterinary journal
Expert Opinion
Tendon boots or bandages and the competition horse
Chapman Stella (2018) — Equine Health
Expert Opinion
Diagnosis of Soft Tissue Injury in the Sport Horse
Bubeck Kirstin A., Aarsvold Stacie (2018) — Veterinary Clinics of North America: Equine Practice
Expert Opinion
Seabaugh Kathryn A, Thoresen Merrilee, Giguère Steeve (2017) — Frontiers in veterinary science
Expert Opinion
Healing soft tissue injuries to the equine distal limb
Chapman Stella (2015) — Equine Health
Expert Opinion
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)
Expert Opinion
Musculoskeletal disease and injury, now and in the future. Part 2: Tendon and ligament injuries.
Clegg P D (2012) — Equine veterinary journal
Expert Opinion
Mesenchymal stem cell therapy in equine musculoskeletal disease: scientific fact or clinical fiction?
Taylor S E, Smith R K W, Clegg P D (2007) — Equine veterinary journal
Expert Opinion
Cytotoxicity of local anaesthetics and protective effects of platelet rich plasma on equine tenocytes: An in vitro study.
Tognoloni Alessia, Pellegrini Martina, Di Salvo Alessandra et al. (2024) — Veterinary journal (London, England : 1997)
Thesis
Examining the Effects of In Vitro Co-Culture of Equine Adipose-Derived Mesenchymal Stem Cells With Tendon Proper and Peritenon Cells.
Pechanec Monica Y, Beall Jessica M, Katzman Scott et al. (2023) — Journal of equine veterinary science
Thesis
Regenerative Medicine for Tendon/Ligament Injuries: De Novo Equine Tendon/Ligament Neotissue Generation and Application
Takashi Taguchi (2023)
Thesis