Time for a Change: Rethinking Tendon Rehab in Horses

When a human athlete injures a tendon, their rehabilitation follows a structured, progressive loading approach that adapts to their individual circumstances and recovery milestones. But when a horse sustains a tendon injury, the rehab process often looks very different—stall rest, strict hand-walking schedules, and a slow return to work based on time rather than physiological response. The question is: Why? And more importantly, should we change our approach?

Comparing Tendon Rehabilitation: Humans vs. Horses

How Human Tendon Rehab Works Tendon rehab is built on the principle of progressive loading—gradually increasing stress on the tendon to stimulate healing and strengthen the tissue. Some of the key approaches include:

• Heavy Slow Resistance (HSR) Training: Lifting progressively heavier weights at a slow, controlled tempo to build tendon strength.
• Tendon Neuroplastic Training (TNT): Using external pacing (e.g., metronomes) to retrain neuromuscular control.
• Relative Rest Instead of Complete Rest: Tendons need load to heal. Athletes reduce intensity rather than eliminating movement altogether.
• Pain as a Guide: Mild discomfort is acceptable, as avoiding all pain often leads to underloading and poor recovery.
  
  

How We Rehab Horses (and Where It Falls Short) In contrast, equine tendon rehab has traditionally focused on:

• Prolonged Rest: Many protocols start with months of box rest, leading to de-conditioning.
• Strict, Gradual Walking Programs: Increasing exercise based on time, rather than placing progressively heavier loads to facilitate adaptation and prepare for a return to work.
• Minimal Strength Training: Unlike humans, where resistance exercises are used to strengthen tendons, horses rarely undergo targeted tendon-loading exercises.
• No individualised approach: The same program is typically prescribed to each horse, regardless of factors such as severity of injury, age, discipline or other co-morbidities. 

The result? Many horses suffer re-injury upon returning to work because their tendons haven’t been conditioned to adapt to the higher loads that come with a return to full work.

Why This Approach Needs to Change
Tendons require mechanical loading to remodel and strengthen. They are mechanosensitive tissues, meaning they require appropriate mechanical loading to stimulate collagen synthesis, maintain structural integrity, and enhance tensile strength. Load reduction is necessary to in cases where injury has occurred, but we should not eliminate all mechanical stimuli. When a horse is kept on strict rest, the tendon doesn’t get the necessary stimulus to adapt. 

Meanwhile, in human athletes, studies show that progressively increasing load leads to better long-term outcomes. The key isn’t avoiding strain altogether but ensuring the appropriate type and amount of load.

Applying Human Rehab Principles to Horses
If we take what works in human medicine and apply it to equine rehabilitation, we may be able to create more effective rehab strategies. Here are some things to consider:
1. Replace Prolonged Stall Rest with Relative Rest

• Instead of complete rest, consider if load reduction is more appropriate, such as reducing frequency or intensity of sessions but not necessarily stopping work altogether. 

2. Incorporate Strength and Neuromuscular Training

• There is no reason to not give more specific exercises, as opposed to just "hand-walking". The use of groundwork exercises, poles, and proprioceptive tools can be applied in early stage rehab if prescribed appropriately.
• Use progressive load increases (increasing the intensity of exercises) rather than time-based progressions (just walking for longer periods of time).

3. Monitor and Adjust Based on Response, Not Just Time

• Instead of rigid timelines (e.g., “six weeks of walking”), use measurable criteria that determines when the horse is ready to progress to the next stage.
• Employ gait analysis tools or simple tracking methods to help guide this.

4. Tailor to the Individual Horse

• Don't employ a "one size fits all" approach, but design a program based on the individual horse, taking into consideration factors such as:
  • age of the horse
  • discipline
  • owner availability, resources and skill
  • severity of the injury
  • other injuries or issues

Where to Learn More
​If you’re ready to rethink equine rehab, explore our book, A Practical Guide to Exercise Prescription in Equine Rehabilitation and EQ Active—a platform designed to help equine professionals create structured, progressive rehab programs.