Functional Anatomy of Tendons and Ligaments in The Distal Limbs (Manus and Pes)

TENDON AND LIGAMENT INJURIES: PART I 0749-0739/94 $0.00 + .
20
FUNCTIONAL ANATOMY OF
TENDONS AND LIGAMENTS IN
THE DISTAL LIMBS
(MANUS AND PES)
Jean-Marie Denoix, DVM, PhD
Tendons and ligaments of the distal limbs of the horse have a prom-
inent anatomic, functional, and clinical importance. During phylogenesis,
equine limbs developed special adaptation for moving at higher speed,
including simplification of the distal extremity to a single and strong
digit, reduction of the muscle components in the distal limbs and devel-
opment of accessory ligaments to reinforce the passive and automatic
behavior of the limbs. Equine tendons and ligaments became very strong
anatomic structures that sustain very high loads and strains, both while
standing and moving; therefore, the function of this elastic and complex
apparatus during weight bearing therefore is twofold-(l) to provide
support to the fetlock and prevent hyperextension of the carpus, and (2)
to restore the energy of impact and full weight bearing during propul-
sion and lift off. This functional importance is doubled by a great clinical
interest because tendon and ligament injuries of the distal limbs are
common problems and are detrimental to the horse industry. Further-
more, the development of new diagnostic methods, such as ultrasonog-
raphy, have increased the need for a more detailed knowledge of tendon
and ligament anatomy.56
This paper was supported by the Institut National de Recherche Agronomique, De-
partment of Animal Pathology, and by the Service des Haras, des Courses et de l'Equita-
tion, Paris, France.
From the Service d' Anatomie--Clinique Equine, Ecole Nationale Veterinaire d' Aifort, Cecex,
France
VETERINARY CLINICS OF NORTH AMERICA: EQUINE PRACTICE
VOLUME 10 • NUMBER 2' AUGUST 1994 273

274 DENOIX
DESCRIPTIVE ANATOMY
The gross anatomy of the tendons and ligaments in the distal fore-
limb and hindlimb of the horse has been described and illustrated. 1, 2, 5, 15,
16, 19, 27, 35, 37, 50, 51 All the anatomic terms used in this article conform with
the international nomenclature,22 Tendon and ligament anatomy varies
between the manus and the pes (distal thoracic and pelvic limbs), but is
quite similar in the digit of the thoracic and pelvic limbs. In each limb
(Figs. 1 and 2), three anatomofunctional entities can be described-the
superficial digital flexor tendon (SOFT) and its accessory ligament (AL-
SOFT); the deep digital flexor tendor (OOFT) and its accessory ligament
(AL-OOFT); and the suspensory apparatus composed by the third in-
terosseous muscle (TIOM), the proximal scutum, and the distal sesa-
moidean ligaments (OSLs). The attachment sites of tendons and liga-
Figure 1. Medial aspect of the carpometacarpal area. 1, Radius; 2, third metacarpal bone;
3, second metacarpal bone; 4, extensor carpi radialis; 5, extensor carpi obliquus; 6, antebra-
chial fascia; 7, flexor retinaculum; 8, distal radial artery; 9, palmar annular ligament; 10,
SDFT; 10a, manica flexoria; 11 , DDFT; 12, AL-DDFT; 13, TIOM; and 14, dorsal digital
extensor tendon.
FUNCTIONAL ANATOMY OF TENDONS AN D LIGAMENTS IN THE DISTAL LIMBS 275
Figure 2. Lateral aspect of the metacarpus. 1, Third metacarpal bone; 2, fourth metacarpal
bone; 3, flexor retinaculum; 4, SDFT; 5, DDFT; 6, AL-DDFT; 7, TIOM ; 7a, body; 7b, lateral
branch; 7c, medial branch; 8, dorsal digital extensor tendon; 9, lateral digital extensor
tendon; and 9a, carpal attachment.
ments to bone (entheses) are of particular interesr9 , 4o and require further

studies in horses because, at least in human medicine, the enthesis is
considered to be the weakest point of the bone-tendon or bone-ligament
functional unit. 41
Superficial Digital Flexor Tendon and its Accessory

Ligament
The body of the superficial digital flexor muscle is attached proxi-

mally to the medial epicondyle of the humerus, has strong tendinous
intersections, and progressively continues to the SOFT in the distal fore-
arm. This tendon also originates from an AL-SOFT inserted on the cau-
domedial aspect of the radius (Fig. 3), 7 to 11 cm proximal to the ante-
brachiocarpal joint. This strong fan-shaped fibrous band, previously
276 DENOIX
Figure 3. Palmaromedial aspect of the carpus. The carpal canal is opened. 1, Radius; 2,
third metacarpal bone; 3, second metacarpal bone; 4, extensor carpi obliquus; 5, flexor carpi
radialis ; 6, tendon sheath of the flexor carpi radialis within the junction between the flexor
retinaculum and the antebrachial fascia ; 7, flexor carpi ulnaris; 8, SDFT; 9, AL-SDFT; 10,
SDF muscle body; 11, DDFT; 12, AL-DDFT; 13, common palmar ligament of the carpus;
and 14, TIOM.
called radial, proximal, or superior check ligament,53 courses distocaudally

and fuses with the tendon just proximal to the antebrachiocarpal joint
(Fig. 3). Medially, it is in contact with the flexor carpi radialis tendon
sheath. Knowledge of this relationship is important in view of the sur-
gical technique of desmotomy of the AL-SOFT as a treatment for meta-
carpophalangeal flexural deformities23 and SOFT injuries. 6
The fused rounded-shaped tendon passes distally through the carpal
canal (discussed subsequently). In the metacarpus, the SOFT becomes
flattened, with a half-moon shape. Its lateral border is sharp and its
medial border round. Histologically, the lateral sharp border is more
cellular than the broader medial part. 62 Behind the palmar (intersesa-
moidean) ligament of the fetlock, its shape becomes symmetric and the
tendon widens greatly. Proximal to the proximal sesamoid bones, a
FUNCTIONAL ANATOMY OF TENDONS AND LIGAMENTS IN THE DISTAL LIMBS 277
fibrous ring called the manica flexoria (Figs. 1 and 4) is attached to its
borders and encircles the DDFT, which passes through it. Distal to the
proximal sesamoid bones, the SDFT becomes progressively thinner in
the sagittal plane and thicker abaxially. At the distal end of the proximal
phalanx, the SDFT distal branches separate and become thicker distally
on each side of the pastern (Fig. 5). They end between the axial and
abaxial palmar ligaments of the proximal interphalangeal joint. All
these anatomic elements insert distally on the scutum medium. This
thick fibrocartilaginous structure is attached to the proximopalmar as-
pect of the middle phalanx and is in contact with the palmar aspect of
the distal condyles of the proximal phalanx dorsally, and to the DDFT
palmarly.
Figure 4. Dorsal aspect of the digital part of the isolated flexor tendons. 1, SDFT; 2, manica
flexoria; 3, distal branches of the SDFT; 4, synovial fold between these branches; 5, DDFT;
5a, enlargement at the palmar aspect of the fetlock; 5b, size reduction at the mid-pastern;
5c, fibrocartilaginous pad palmar to the proximal part of the middle phalanx; 5d, widening at
the palmar aspect of the distal sesamoid bone; and 6, distal attachment of the digital sheath
synovial membrane.
278 DENorx
Figure 5. Palmomedial aspect of the

digit. 1, Ungular cartilage (sectioned); 2,
digital cushion (partially removed); 3, pal-
mar annular ligament; 4, proximal digital
annular ligament; 5, distal digital annular
ligament; 6, SOFT distal branch; 7,
OOFT; 8, mesotendon of the OOFT seen
through the digital sheath wall; 9, proper
palmar digital artery; 10, ramus tori ; and
11, distal branch for the OOFT.
Deep Digital Flexor Tendon and its Accessory

ligament
The deep digital flexor muscle consists of three heads. The principal
one, the humeral head, contains collagenous intersections and is pro-
vided with a strong tendon. This tendon appears about 8 to 10 cm
proximal to the antebrachiocarpal joint (see Fig. 3), but muscle bundles
remain within it until the level of that joint, where it is joined by the
tendons of the two other (ulnar and radial) heads. The broad, conjoined
OOFT has a triangular cross-sectional shape in the carpal canal and
becomes progressively narrower and round in the proximal metacarpus.
At about the middle of the metacarpus, it blends with its AL-OOFT,
previously called the subcarpal, distal, or inferior check ligamenP3 (see Figs.
1-3). This strong fibrous band is the direct continuation of the common
palmar ligament of the carpus. Proximally, it is broad and has a rectan-
gular shape; it becomes progressively narrower and thicker distally and
then molded on the dorsal aspect of the OOFT. At the lateral and medial
aspects of the OOFT, a member of fibrous bundles join the SOFT, predis-
posing to adhesions between the AL-OOFT and the SOFT in pathologic
conditions. The corresponding ligament is thinner in the hindlimb. 1, 53
The OOFT results from the union of a strong lateral digital flexor tendon
and a thin medial digital flexor tendon. The lateral digital flexor tendon
incorporates the caudal tibialis tendon and passes over the sustentacu-
lum tali within the plantar tarsal sheath. The medial digital flexor tendon
passes over the proximal tubercle of the talus, at the medial aspect of the
tarsus in its own sheath. These two tendons fuse in the proximal meta-
tarsus. In the distal third of the metacarpus (metatarsus), the DDFT has
incorporated all the fibers of its accessory ligament, becomes oval, and
passes through the manica flexoria (see Figs. 1,3,4).
Behind the proximal scutum, it becomes considerably wider, elliptic,
and fibrocartilaginous. At the level of the proximal half of the proximal
phalanx, the DDFT is divided into two round, symmetric parts in which
its fibers adopt a spiral disposition. Its dorsopalmar thickness and its
lateromedial width decrease distally (see Fig. 4). The narrowest cross-
sectional area is located in the middle of the proximal phalanx, where
the DDFT passes between the two distal branches of the SOFT and
becomes superficial (see Fig. 5). Palmar to the distal half of the proximal
phalanx, the size of the DDFT increases in dorsopalmar and lateromedial
directions. At the level of the proximal part of the middle phalanx, the
dorsal half of the tendon becomes a distinct fibrocartilaginous pad prox-
imal to the distal sesamoid bone (see Fig. 4). Distally, the DDFT is
molded to the contour of the palmar aspect of the navicular bone. It is
broad and forms a terminal fanlike expansion, containing cartilage, oc-
cupying the entire width of the space between the lateral and medial
palmar processes of the distal phalanx. The DDFT ends on the facies
flexoria (Fig. 6) of the distal phalanx, delineated dorsally by the semilu-
nar line and the adjacent surface of the ungular cartilage.
Third Interosseous Muscle and Distal

Sesamoidean Ligaments
The nOM is a strong tendinous band, long known for its role as the
suspensory ligament (Fig. 7). In the forelimb, the nOM arises proximally
from the distal row of the carpal bones and from the adjacent parts of
the palmar aspect of the proximal extremity of the metacarpal bones-
principally the third metacarpal bone. I. 2 The proximal part of the nOM
is incompletely separated into two main divisions originating from the
second and third carpal bones. Extension of palmar recesses of the car-
pometacarpal synovial cavity extend 1 to 2 cm distal to the origin of the
nOM. In the hindlimb, the main area of attachment is at the proximal
and plantaromedial aspect of the third metatarsal bone; there is less
extensive attachment to the plantar tubercle of the first, third, and fourth
tarsal bones. A distal recess of the tarsometatarsal joint is in contact with
the lateral aspect of the proximal nOM in some horses.
The body of the nOM descends between the second and fourth
metacarpal bones (see Fig. 7), in the metacarpal groove, and gradually is
separated from the palmar aspect of the third metacarpal bone. The level
at which it divides into two symmetric or asymmetric diverging branches
varies among horses, but appears between mid-metacarpus and the dis-
tal fourth of this area (see Fig. 7).
The abaxial aspects of these two strong distal branches are easily
280 DENOIX
Figure 6. Magnetic resonance imaging sagittal section of the digit. 1, Proximal phalanx; 2,
middle phalanx; 3, distal phalanx; 4, distal sesamoid bone; 5, dorsal digital extensor tendon;
6, SOFT; 7, OOFT; 7a, fibrocartilaginous pad palmar to the proximal part of the middle
phalanx; 7b, distal part with a hypersignal; 8, oblique sesamoidean ligament; 9, straight
sesamoidean ligament; 10, collateral sesamoidean ligaments; 11, distal sesamoidean liga-
ment; and 12, digital cushion .
palpated on the live horse. These branches insert on the abaxial surface
(interosseous face) of the corresponding proximal sesamoid bone. Each
branch detaches a thin extensor branch dorsodistally that obliquely
crosses the proximal phalanx axis and joins the dorsal digital extensor
tendon (DDET) just above the proximal interphalangeal joint. Each exten-
sor branch blends with the corresponding collateral sesamoidean liga-
ment proximally, and there is a small subtendinous bursa between the
extensor branch and the proximolateral aspect of the proximal phalanx.
In the forelimb, the nOM is rectangular, strong, and about 20 to 25
cm long. In the hindlimb, it is thinner, round, and 25 to 30 cm long.
Although it is mainly collagenous, it contains variable amounts of
striated muscular fibers,! ' 63 especially in the proximal and deep part. No
significant difference occurs in the muscle content with age. 63 The muscle
fibers are organized into two longitudinal bundles within the proximal
part and the body of the nOM.93 Standardbreds have 40% more muscle
FUNCTIONA L ANATOMY OF TENDO NS AND LIGAM ENTS IN THE DISTAL LIMBS 281
Figure 7. Palmar aspect of the metacarpus. 1, Third metacarpal bone; 2, second metacarpal
bone; 3, fourth metacarpal bone; 4, TIOM; 4a, proximal part; 4b, body; 4c, lateral branch;
4d, medial branch; 5, medial collateral ligament of the carpus; 6, lateral collateral ligament
of the carpus; 7, accessoriometacarpalligament; 8, palmar (intersesamoidean) ligament; 9,
attachment to the TIOM medial branch; 10, straight sesamoidean ligament; 11, oblique
sesamoidean ligament.
in their TIOM than Thoroughbreds (14% versus 10% of total area).93

Thoroughbred horses in training have significantly less muscle content
in their TIOM than horses of the same age not in training. Muscle content
is significantly greater in the hindlimb than in the forelimb in Stan-
dardbreds; the opposite distribution is observed in Thoroughbreds, but
the difference is not significant.93
The DSLs represent the functional continuation of the TIOM in the
digit (see Fig. 6). They are formed by the straight sesamoid ligament
(SSL), oblique sesamoidean ligaments (OSL), cruciate sesamoidean liga-
ments (CSL), and short sesamoidean ligaments (sSL). All are attached
proximally to the base of the proximal sesamoid bones and the palmar
ligament, but their respective distal insertion differs.
The SSL, the most palmar ligament of the DSL, is a flat band, 5 to
282 DENOIX
9 mm thick, and wider proximally than distally (Fig. 8). Proximally, it

has a trapezoidal cross-sectional shape, with its larger concave base fac-
ing palmarly. The SSL becomes oval and its thickness increases progres-
sively distally as its size decreases in a lateromedial direction. Distally, it
is attached to the scutum medium in the sagittal plane.
The OSLs represent the intermediate or middle ligaments of the DSL
(see Fig. 8); on each palmoabaxial aspect of the proximal phalanx lies a
strong ligament with a triangular cross-sectional shape and rounded
margins. Between these two main parts, thicker abaxially, runs a thin
sagittal portion. Sagittally, the thickness of the OSL increases progres-
sively distally because of the convergence of the abaxial ligaments in the
sagittal plane. The OSLs insert to the rough triangular area on the palmar
aspect of the proximal phalanx and end between the proximal insertion
of the two axial palmar ligaments of the proximal interphalangeal (PIP)
joint at the distal third of the proximal phalanx. The palmar artery and
vein of the proximal phalanx run between the SSL and the OSL in the
middle third of the proximal phalanx (see Fig. 8).
The CSLs form the palmar wall of the distopalmar synovial recess
of the metacarpophalangeal joint. They consist of two thin layers of fibers
crossing each other and ending on the axial aspect of the proximopalmar
tuberosity of the proximal phalanx. The sSLs are difficult to differentiate
from the deep aspect of the OSL and are best seen by examining the
sesamoidophalangeal space dorsally.
Figure 8. Palmar aspect of the digit.

1, Palmar (intersesamoidean) ligament;
2 , straight sesamoidean ligament; 3,
oblique sesamoidean ligament; 4, scu-
tum medium; 5, SOFT distal branches; 6,
palmar aspect of the proximal part of the
middle phalanx; 7, OOFT reflected pal-
mad; 8, distal recess of the digital
sheath; 9, proper palmar digital artery
and vein (the vein has been partially re-
moved); 10, palmar branches of the
proximal phalanx; and 11 , palmar
branches of the middle phalanx.
FUNCTIONAL ANATOMY OF TEN DONS AND LIGAMENTS IN THE DISTAL LIMBS 283
Carpal Canal
The walls of the carpal canal are composed of several structures: (1)
The dorsal wall is formed by the common palmar ligament of the carpus,
which represents a thickened palmar part of the fibrous joint capsule; it
continues distally as the AL-OOFT. (2) The palmaromedial wall is the
flexor retinaculum stretched from the accessory carpal bone and its liga-
ments laterally to the distal radius, radial carpal, second (and first) carpal
bones, proximal second metacarpal bone, and medial collateral ligament
of the carpus medullae. Its proximal border continues the caudal antebra-
chial fascia and its distal border continues the palmar metacarpal fascia.
Proximally, the AL-SOFT contributes to form the medial wall of the
carpal canal (Fig. 9). (3) The lateral wall of the carpal canal is supported
by the accessory carpal bone extended distally by the accessorioquartale
and accessoriometacarpeum ligaments.
Carpal hyperextension is limited by the widespread fibrous tissue,
including the retinaculum flexorum and its continuation in the distal
antebrachial fascia and palmar metacarpal fascia (see Fig. 9). The same
eccentric position of the ligaments that attach to the accessory bone also
limits carpal hyperextension.
The SOFT and OOFT pass through the carpal canal enveloped in a
common carpal synovial sheath (Fig. 10). This sheath extends from 7 to
10 cm proximally to the antebrachiocarpal joint until the proximal third
or middle of the metacarpus distally. The proximal recess is wide and
firmly covered medially by the strong antebrachial fascia; laterally, it
covers the OOF muscle and extends between the ulnaris lateralis and
lateral digital extensor muscle (Fig. 11). Synovial distention induces fluid
accumulation between these muscles, proximal to the accessory carpal
bone. The distal recess extends between the OOFT and the AL-OOFT.
Synovial distention induces herniation at the medial or lateral aspect of
the OOFT.
Digital Sheath
The palmar wall of the digital sheath is composed of two annular

ligaments-the palmar annular ligament and the proximal digital annu-
lar ligament (see Fig. 4). The palmar annular ligament inserts on the
palmar border of the proximal sesamoid bones. This strong transverse
ligament binds down the flexor tendons and converts the proximal scu-
tum (proximal sesamoid bones and palmar ligament) into a real canal.
The proximal digital annular ligament is a thinner quadrilateral sheet
lying immediately underneath the skin and, in great part, adherent to
the SOFT. In sound limbs, it is very difficult to differentiate it from the
SOFT itself at the palmar aspect of the digit. It is attached on either side,
to the proximopalmar tuberosity of the proximal phalanx by a well-
defined band; the distal attachment adheres to the distal branch of the
SOFT and inserts with it on the distal part of the proximal phalanx.
284 DENOIX
6------..~
~ff_'H_-----7
r7Tffi7.r-------10
1~------~~~~
1-------2
~~~--------14
~::>------15
--------11
~~---------16
11:1"---------12
1~-------5
Figure 9. Palmaromedial view of the carpal sheath walls and accessory ligaments of the
flexor tendons. 1, Radius; 2, accessory carpal bone; 3, third metacarpal bone; 4, second
metacarpal bone; 5, fourth metacarpal bone; 6, flexor carpi radialis; 6a, flexor carpi radialis
digital sheath; 7, flexor carpi ulnaris; 8, ulnaris lateralis; 9, extensor carpi obliquus; 10, AL-
SOFT; 11, AL-OOFT; 12, TIOM; 13, antebrachial fascia; 14, flexor retinaculum; 15, palmar
metacarpal fascia, and 16, deep palmar metacarpal fascia.
Figure 10. Palmaromedial aspect of the

carpus. The retinaculum flexorum has
been sectioned and reflected; therefore,
the carpal canal is opened. 1, Radius; 2,
third metacarpal bone; 3, second meta-
carpal bone; 4, extensor carpi obliquus;
5, flexor carpi radialis; 6, flexor carpi ul-
naris; 7, SDFT; 8, DDFT; 9, AL-DDFT;
10, TIOM; 11, synovial sheath of the car-
pal canal; and 12, AL-SDFT.
Figure 11. Transverse cross-section in the distal forearm. 1, Radius; 2, craniolateral wall of
the carpal canal; 3, ulnaris latera lis muscle; 4, flexor carpal ulnaris muscle; 5, flexor carpal
radialis tendon; 6, proximal part of the flexor retinaculum; 7, superficial digital flexor tendon;
8, accessory ligament of the SDFT; 9, deep digital flexor tendon; 10, carpal sheath; 11,
median artery, vein, and nerve; 12, distal radial artery and cephalic vein; and 13, ulnar nerve
and collateral ulnar artery and vein.
286 DENOIX
The dorsal wall of the digital sheath is formed by the palmar aspect
of the palmar (or intersesamoidean) ligament, DSL, scutum medium
(thick fibrocartilaginous structure attached to the proximopalmar aspect
of the middle phalanx), and middle phalanx.
The digital synovial sheath begins 4 to 7 cm proximal to the proxi-
mal sesamoid bones and extends distally to the half middle phalanx (Fig.
12). It has several recesses20 :
(1) The proximal recess is located proximal to the manica flexoria
and palmar annular ligament in the distal fourth of the metacar-
pus. Between the distal branches of the nOM, it is in contact
with digital veins and arteries and with the proximopalmar
articular recess of the metacarpophalangeal joint.
(2) The collateral recesses are located on the lateral and medial
aspects of the pastern, between the flexor tendons and the DSL.
The proximal attachment of the proximal digital annular liga-
ment separates a small proximal recess below the proximal ses-
amoid bone and a large distal recess behind the proximal half
of the proximal phalanx. Behind the proximal sesamoid bones
and proximal half of the proximal phalanx, the SDFT is widely
adherent sagittally to the proximal digital annular ligament, so
no fluid is present in this location.
(3) The distal recess extends between the middle phalanx and the
dorsal aspect of the DDFT and is separated by a thin wall from
the proximal recess of the podotrochlear bursa and the proxi-
Figure 12. Oorsopalmar contrast radio-

graph of the digital sheath 10 minutes
after injection. 1, Proximal recess; 2, col-
lateral recesses; 3, distal recess of the
digital sheath; 4, OOFT radiolucent filling
defect; 5, manica flexoria; 6, SOFT
branch; 7, proximal attachment of the
proximal digital annular ligament; 8, dis-
tal border of the proximal digital annular
ligament; and 9, OOFT mesotendon fill-
ing defect.
mopalmar recess of the distal interphalangeal (DIP) joint. At the

palmar aspect of the DDFT, between the two digital annular
ligaments, the distal recess presents a palmar pouch divided
sagittally by the DDFT meso tendon. It is this palmar part that
deforms the palmar profile of the pastern when the digital
sheath is distended. The digital sheath facilitates displacement
of the flexor tendons during flexion and extension movements
of the metacarpophalangeal and interphalangeal joints. During
metacarpophalangeal movements, the two flexor tendons slide
together. During interphalangeal movements, the DDFT dis-
placements are much greater than those of the SDFT. Sliding of
the flexor tendons during digital joint movements can be im-
aged with ultrasonography.
The distal digital annular ligament is adherent to the palmar sur-
face of the distal part of the DDFT and binds down the terminal expan-
sion of this tendon. It is a crescentic fibrous sheet attached by a strong
band, covering the distal branch of the SDFT, on either side of the middle
of the proximal phalanx.
Podotrochlear Bursa
The podotrochlear bursa (navicular bursa) is between the DDFT and

the distal sesamoid bone. Its proximal recess extends 1 to 2 cm proximal
to the distal sesamoid bone and is applied closely to the proximopalmar
recess of the DIP joint and the distal recess of the digital sheath. Its distal
recess separates the distal sesamoidean ligament and the terminal part
of the DDFT.
Vessels and Nerves
Vessels
Several arteries supply the SDFT.59 A "nutrient artery" coming from
the median artery is described associated closely with the AL-SDFT30 and
enters the tendon at the transition between muscle and tendon (at the
proximal part of the tendon). Near the proximal border of the palmar
annular ligament and on either side of the limb, passing within the
mesotendon, the proper digital artery gives off an arterial branch (distal
metacarpal branch) that carries blood to the SDFT (Fig. 13). Near the
distal border of the palmar annular ligament, a proximal digital branch
also reaches the SDFT.5, 34 These branches must be preserved during
surgical interventions in this area. Complementary supply comes from
the muscle body; the peritendon in the metacarpal region; the sagittal
adhesion with the proximal digital annular ligament; and the perios-
teum, close to the distal insertion. 59 All these branches contribute to
supply an extensive intra tendinous arterial network and two major
288 DENOIX
vessels located at the medial and lateral aspects of the SOFT in the
metacarpal area. Within the tendon, longitudinal arterioles course be-
tween fiber bundles and anastomize with fine perpendicular branches.3°
The vascularization of the normal DDFT has been studied through
gross dissection and angiography within the digital sheath, which re-
vealed three major sources. 21 Proximal to the fetlock, near the proximal
recess of the digital sheath, the common digital artery gives off a distal
metacarpal branch running distally at the palmar aspect of the tendon.
Distal to the fetlock, one or two vessels arising from the palmar branches
of the proximal phalanx reach the dorsal aspect of the tendon and supply
a dorsal sagittal artery. The terminal part of the tendon is supplied by
two symmetric small vessels arising on each side of the tendon from the
proper digital artery (Fig. 14). Microangiography reveals an extensive
intra tendinous vascular network within the DDFT, except in the region
palmar to the fetlock. 21 In that area, variable amounts of fibrocartilage
can be found in the tendon, and vessels are scarce.
Nerves
The nOM is innervated by the palmar metacarpal nerves arising
from the deep ramus of the palmar branch of the ulnar nerve. Because of
a distal antebrachial communicating branch from the median nerve to
the palmar branch of the ulnar nerve, the nOM is supplied partially by
median nerve fibers.
Figure 13. Palmar aspect of the digit. 1,

Palmar annular ligament: this ligament is
sectioned sagittally, and the lateral part
is reflected to allow visualization of the
SOFT arteries; 2, proximal digital annular
ligament; 3, SOFT; 4, proper palmar dig-
ital artery; 5, distal metacarpal anasto-
mosis of the SOFT; and 6, proximal digi-
tal anastomosis of the SOFT.
Figure 14. Palmar aspect of the distal

digit. 1, Distal digital annular ligament:
this ligament is sectioned sagittally, and
the lateral and medial parts are reflected
to allow visualization of the DDFT; 2,
8DFT distal branches; 3, DDFT; 4, pal·
mar wall of the digital sheath; 5, proper
palmar digital artery; 6, sagittal palmar
arteries of the DDFT; and 7, distal abax·
ial branch of the proper digital artery for
the terminal portion of the DDFT.
The metacarpal part of the flexor tendons is supplied by the palmar

common digital nerves; the medial one is the direct continuation of the
median nerve; the lateral one gets its fibers from the ulnar and median
nerves.
A second large metacarpal communicating branch, coming from the
medial (second) common palmar digital nerve to the lateral (third) com-
mon palmar digital nerve, obliquely crosses the palmar aspect of the
SOFT, generally near the middle of the metacarpus.
The digital part of the flexor tendons is supplied by the proper
digital nerves.
TOPOGRAPHIC ANATOMY AND CROSS-SECTIONS

Carpal Canal
The flexor tendons are included in the carpal synovial sheath, with
the median artery and the medial palmar common digital nerve contin-
uing the median nerve (Figs. 11, 14-17). All these structures are enve-
loped in the same synovial sheath inner wall, attached medially to the
outer wall.
Metacarpus
In the proximal two thirds of the metacarpus, the following palma-
rodorsal sequence is found-SOFT, OOFT, AL-OOF, and TIOM body
290 DENOIX
Figure 15. Sagittal section of the carpus. 1, Radius; 2, radial carpal bone; 3, intermediate
carpal bone; 4, third carpal bone; 5, third metacarpal bone; 6, common dorsal ligament; 7,
extensor carpal radialis tendon; 8, common palmar ligament; 9, antebrachioradial ligament;
10, superficial digital flexor tendon; 11, accessory ligament of the SOFT; 12, deep digital
flexor tendon; 13, accessory ligament of the OOFT; 14, third interosseous muscle; 15, flexor
retinaculum; 16, flexor carpi ulnaris muscle; 17, lateral common digital vein and ulnar nerve;
and 18, deep proximal metacarpal vascular anastomosis.
Figure 16. Transverse cross-section of the carpus in the middle of the proximal row. 1,
Radial carpal bone; 2, intermediate carpal bone; 3, ulnar carpal bone; 4, accessory carpal
bone; 5, interosseous ligaments; 6, medial collateral ligament; 7, lateral collateral ligament;
8, common dorsal ligament; 9, extensor carpi radialis tendon; 10, dorsal digital extensor
tendon; 11, long tendon of the ulnaris lateralis muscle; 12, flexor retinaculum; 13, common
palmar ligament; 14, flexor carpi radialis tendon; 15, superficial digital flexor tendon; 16,
deep digital flexor tendon; 17, carpal canal; 18, median artery and nerve; 19, ulnar nerve
and collateral ulnar vein and artery; and 20, distal radial artery and cephalic vein.
(Figs. 18-21). In the distal third, only three tendon layers are present-
SDFT, DDFT, and nOM branches.
Fetlock
The two flexor tendons are bound in the proximal scutum (made of
the two proximal sesamoid bones and the palmar or intersesamoidean
ligament) by the palmar annular ligament, which fuses sagittally with
the SDFT (Figs. 22-25).
Pastern
The shape and relationships of the anatomic structures of the pastern

vary in a proximo distal direction, so the pastern can be divided into
several distinct areas. Three of these can be differentiated at the palmar
aspect of the proximal phalanx-the proximal, intermediate, and distal
parts. An additional area can be identified at the level of the PIP joint
and proximal part of the middle phalanx.
292 DENOIX
Figure 17. Transverse cross-section of the distal row. 1, Second carpal bone; 2, third carpal
bone; 3, fourth carpal bone; 4, medial collateral ligament; 5, lateral collateral ligament; 6,
palmolateral recess of the carpometacarpal joint; 7, extensor carpal radialis tendon; 8, dorsal
digital extensor tendon; 9, common palmar ligament; 10, flexor retinaculum; 11, superficial
digital flexor tendon; 12, deep digital flexor tendon; 13, carpal canal; 14, medial palmar
common digital artery; 15, medial palmar common digital vein; and 16, lateral palmar com-
mon digital vein.
Proximal Part of the Proximal Phalanx
The palmar (metacarpophalangeal) annular ligament lies immedi-

ately underneath the skin and is fused with the SOFT (Figs. 26, 27).
Beneath this tendon, the OOFT is separated from the OSL by the digital
sheath. The different layers of the OSL cover the palmar aspect of the
proximal part of the proximal phalanx.
Middle Part of the Proximal Phalanx

The wall of the digital sheath (proximal digital annular ligament) is
very thin and adheres to the SOFT (Figs. 26, 28). The SOFT distal
branches diverge progressively on each side of the pastern. The OOFT
emerges between these branches. On the dorsal aspect of that tendon lies
a thin synovial fold of the digital sheath. The SSL runs parallel to the
OOFT. The OSLs end at the distal third of the proximal phalanx between
the proximal insertion of the two palmar ligaments of the PIP joint. The
palmar artery and vein of the proximal phalanx run between the SSLs
and the OSLs in the middle third of the proximal phalanx.
Text continued on page 297
Figure 18. Sagittal section of
the proximal metacarpus. 1, Third
carpal bone; 2, third metacarpal
bone; 3, distal insertion of the ex-
tensor carpi radialis ; 4, superficial
digital flexor tendon; 5, deep digi-
tal flexor tendon; 6, accessory lig-
ament of the DDFT; 7, third inter-
osseous muscle (with striated
muscle bundles); 8, flexor retinac-
ulum; 9, palmar metacarpal fas-
cia; and 10, palmar metacarpal
vein.
Figure 19. Transverse cross-section of

the proximal metacarpus. 1, Third meta-
carpal bone; 2, second metacarpal bone;
3, fourth metacarpal bone; 4, dorsal digi-
tal extensor tendon; 5, lateral digital ex-
tensor tendon; 6, superficial digital flexor
tendon; 7, deep digital flexor tendon; 8,
accessory ligament of the DDFT; 9, third
interosseous muscle; 10, palmar meta-
carpal fascia ; 11 , distal recess of the car-
pal sheath ; 12, medial palmar common
digital artery; 13, medial palmar com-
mon digital vein; 14, medial palmar com-
mon digital nerve; 15, lateral palmar
common digital vein and nerve; and 16,
palmar metacarpal artery and vein.
293
294 DENOIX
Figure 20. Transverse cross-section in the

middle of the metacarpus. 1, Third meta-
carpal bone; 2, second metacarpal bone;
3, fourth metacarpal bone; 4, dorsal digital
extensor tendon; 5, lateral digital extensor
tendon; 6, superficial digital flexor tendon;
7, deep digital flexor tendon; 8, accessory
ligament of the DDFT; 9, third interosseous
muscle; 10, palmar metacarpal fascia; 11,
medial palmar common digital artery; 12,
medial palmar common digital vein; 13,
medial palmar common digital nerve; 14,
lateral palmar common digital vein and
nerve; and 15, palmar metacarpal vein and
artery.
Figure 21. Transverse cross-section in the

distal metacarpus. 1, Third metacarpal
bone; 2, second metacarpal bone; 3, fourth
metacarpal bone; 4, dorsal digital extensor
tendon; 5, lateral digital extensor tendon;
6, superficial digital flexor tendon; 7, deep
digital flexor tendon; 8, third interosseous
muscle medial branch; 9, third interosse-
ous muscle lateral branch; 10, proximal
recess of the digital sheath; 11, medial pal-
mar common digital artery; 12, anastomo-
sis of the common digital veins; and 13,
palmar metacarpal artery and vein.
Figure 22. Sagittal section of the meta-

carpophalangeal joint. 1, Third metacar-
pal bone; 2, metacarpal condyle; 2a,
sagittal ridge; 3, proximal phalanx; 4, sy-
novial membrane; 5, synovial cavity; 6,
palmar ligament (intersesamoidean); 7,
straight sesamoidean ligament; 8, cru-
ciate sesamoidean ligaments; 9, superfi-
cial digital flexor tendon; 9a, manica flex-
oria; 10, deep digital flexor tendon; 11,
palmar annular ligament; 12, digital
sheath proximal recess; 13, arterial
anastomosis; and 14, palmar vein.
Figure 23. Transverse section of the meta-

carpophalangeal joint proximal to the inter-
sesamoidean ligament. 1, Third metacar-
pal bone; 2, proximal palmar recess of the
metacarpophalangeal joint; 3, dorsal digital
extensor tendon; 4, lateral digital extensor
tendon; 5, third interosseous muscle; Sa,
lateral branch; 5b, medial branch; 6, super-
ficial digital flexor tendon; 6a, manica flex-
oria; 7, deep digital flexor tendon; 8, digital
sheath; 9, palmar metacarpal artery; 10,
arterial anastomosis; 11, metacarpal vein;
and 12, common digital vein.
296 DENOIX
Figure 24. Transverse section of the

metacarpophalangeal joint proximal to
the proximal sesamoid bones. 1, Third
metacarpal bone; 2, joint capsule of the
metacarpophalangeal joint; 3, proximal
palmar recess of the synovial cavity; 4,
palmar ligament; 5, medial collateral lig-
ament; 6, dorsal digital extensor tendon;
7, lateral digital extensor tendon; 8a,
third interosseous muscle lateral branch;
8b, third interosseous muscle medial
branch ; 9, Superficial digital flexor ten-
don; 9a, manica flexoria; 1D, deep digital
flexor tendon; 11 , digital sheath; 12, pal-
mar proper digital artery; 13, palmar
proper digital vein ; and 14, palmar proper
digital nerve.
Figure 25. Transverse section of the metacarpophalangeal joint near the base of the proxi-
mal sesamoid bones. 1, Third metacarpal bone; 1a, sagittal ridge ; 2, proximal sesamoid
bone; 3, palmar (intersesamoidean) ligament; 4, collateral sesamoidean ligament; 5, exten-
sor branch of the TIOM; 6, superficial digital flexor tendon; 7, deep digital flexor tendon; 8,
palmar annular ligament; 9, digital sheath cavity; 1D, palmar proper digital artery; 11, palmar
proper digital vein; and 12, palmar proper digital nerve.
Figure 26. Sagittal section of the digit. 1, Third metacarpal bone; 2, proximal phalanx; 3,
middle phalanx; 4, distal phalanx; 5, distal sesamoid bone; 6, intersesamoidean ligament; 7,
cruciate sesamoidean ligament; 8, oblique sesamoidean ligament; 9, straight sesamoidean
ligament; 10, dorsal articular capsule; 11 , scutum medium; 12, collateral sesamoidean liga-
ment; 13, distal sesamoidean ligament; 14, dorsal digital extensor tendon; 15, deep digital
flexor tendon; 16, superficial digital flexor tendon; 17, palmar annular ligament; 18, proximal
digital annular ligament; 19, distal digital annular ligament; 20, digital sheath; 21, podotroch-
lear bursa; and 22, digital cushion.
Distal Part of the Proximal Phalanx
At this level, the synovial membrane is separated from the skin by a

very thin palmar digital fascia (Figs. 26, 29). The OOFT is adjacent to the
distal aspect of the SSL and then, distally, the scutum medium. The distal
part of the proximal phalanx is covered axially by the distal part of the
SSL. Laterally and medially, this structure is separated from the end of
the distal branch of SOFT by the axial palmar ligament of the PIP joint.
On each side of the pastern, the distal branch of the SOFT ends between
the axial and abaxial palmar ligaments of the PIP joint. All these ana-
tomic elements insert distally on the scutum medium.
298 DENOIX
Figure 27. Transverse section of the digit at the level of the proximal part of the proximal
phalanx. 1, Proximal phalanx; 2, oblique sesamoidean ligament; 3, straight sesamoidean
ligament; 4, distopalmar recess of the metacarpophalangeal joint; 5, superficial digital flexor
tendon; 6, deep digital flexor tendon; 7, proximal digital annular ligament; 8, proprius digital
artery; 9, proprius digital vein; 10, proprius digital nerve; and 11, ergot.
Figure 28. Transverse section of the digit near the middle of the proximal phalanx. 1,
Proximal phalanx; 2, oblique sesamoidean ligament; 3, straight sesamoidean ligament; 4,
superficial digital flexor tendon; 5, deep digital flexor tendon; 6, proximal digital annular
ligament; 7, digital sheath; 8, proprius digital artery; 9, dorsal branch of the proximal phalanx;
10, proprius digital vein; 11, palmar branch of the proximal phalanx; 12, proprius digital
nerve.
Figure 29. Transverse section of the digit at the level of the distal part of the proximal
phalanx. 1, Proximal phalanx; 2, palmar recess of the proximal interphalangeal joint (PIP);
3, scutum medium; 4, distal attachment of the SOFT on the proximal phalanx; 5, deep digital
flexor tendon; 6, palmar wall of the digital sheath; 7, proprius digital artery; 8, proprius digital
vein; and 9, proprius digital nerve.
Figure 30. Frontal section of the digit

passing through the palmar aspect of
the proximal phalanx, middle phalanx,
and distal sesamoid bone. 1, Proximal
phalanx (proximopalmar tubercle); 2,
middle phalanx (tuberositas flexoria); 3,
distal phalanx (palmar process); 4, dis-
tal sesamoid bone (palmar cortex); 5,
palmar (intersesamoidean) ligament; 6,
scutum medium; 7, palmar recess of
the DIP joint; 8, superficial digital flexor
tendon distal branch; 9, deep digital
flexor tendon; 10, digital sheath cavity;
11, podotrochlear bursa; 12, proprius
digital artery; 13, digital cushion; and
14, ungular cartilage.
300 DENOIX
Proximal Interphalangeal Joint and Proximal Part of the

Middle Phalanx
The palmar aspect of the distal condyles of the proximal phalanx is
in contact with the scutum medium (Figs. 26, 30, 31). At the level of the
proximal part of the middle phalanx, the DDFT is adjacent to the fibro-
cartilaginous surface of the tuberositas flexoria. It is separated from the
skin by a thin distal annular ligament. Between these two structures, the
synovial membrane is thicker sagittally and adheres to the palmar aspect
of the DDFT.
Foot
The palmar surface of the distal digital annular ligament is widely

covered by the digital cushion (Figs. 31-33). Dorsally, this ligament ad-
heres to the DDFT, which is molded over the facies flexoria of the distal
sesamoid bone.
Pes
The anatomy in the metatarsus is different from that in the metacar-

pus (Fig. 34). In the proximal metatarsus, the DDFT components are on
the dorsomedial aspect of the SDFT, the lateral border of which is
thicker. The nOM has a rounder shape than in the forelimb and is in
contact with a large plantar metatarsal vein.
MECHANICAL PROPERTIES AND FUNCTIONAL

ANATOMY
General Considerations
Tendons and ligaments have several important roles during loco-

motion and in the standing position: They act as force transmitters and
joint coaptaters, with an especial involvement in fetlock suspension. As
elastic structures, they have a major role as impact absorbers and have
the ability to store and release energy, reducing the energy cost of loco-
motion, especially at high speeds.
In the hindlimbs of adult horses of various breeds, the cross-sec-
tional area (CSA) of the SDTF, DDFT, and nOM varies considerably in
a proximodistal direction and among horses.43 There is an inverse rela-
tionship between the cross-sectional area and the collagen content as
well as tendon fibers, so the CSA is not representative of the local
strength of equine tendons. 43 Another study44 demonstrated that loaded
equine hindlimb tendons are strained homogeneously. As a result, the
modulus of elasticity is inversely proportional to the corresponding CSA
and proportional to the collagen content. The increase in CSA by non-
Figure 31. Transverse section of the foot at the level of the proximal part of the middle
phalanx. 1, Middle phalanx (tuberositas flexoria); 2a, deep digital flexor tendon: fibrous part;
2b, deep digital flexor tendon: fibrocartilaginous part; 3, distal digital annular ligament; 4,
digital sheath; 5, digital cushion; 6, proprius digital artery; 7, branches for the digital torus; 8,
venous plexus at the deep aspect of the ungular cartilage; and 9, ungular cartilage .
load-bearing collagen, glycosaminoglycans, and cells, is due to functions

such as assimilation of compression forces when the limb axis deviates. 43
Anatomic changes along the length of the equine digital flexor tendon
are accompanied by extracellular matrix composition changes.26 It has
been suggested that these variations in tissue structure are influenced by
Figure 32. Transverse section of the foot at the level of the proximal border of the distal
sesamoid bone . 1, Middle phalanx; 2, distal sesamoid bone; 3, distal interphalangeal joint
(DIP); 4, collateral sesamoidean ligament; 5, deep digital flexor tendon; 6, distal digital
annular ligament; 7, podotrochlear bursa; 8, digital cushion; 9, ungular cartilage; and 10,
proprius digital artery.
302 DENOIX
Figure 33. Transverse section of the foot at the level of the distal border of the distal
sesamoid bone. 1, Distal phalanx; 1a, articular cartilage of the PIP joint; 1b, palmar process;
2, distal sesamoid bone (distal border); 3, distal interphalangeal joint (DIP); 4, collateral
ligament of the DIP joint; 5, deep digital flexor tendon; 6, podotrochlear bursa; 7, proprius
digital artery; 8, digital cushion; and 9, ungular cartilage.
Figure 34. Transverse cross·section in the

middle of the metatarsus. 1, Third metatar-
sal bone; 2, second metatarsal bone; 3,
fourth metatarsal bone; 4, long digital exten-
sor tendon; 5, superficial digital flexor ten-
don; 6, deep digital flexor tendon ; 7, acces-
sory ligament of the DDF tendon; 8, third
interosseous muscle; 9, third dorsal metatar-
sal artery; 10, lateral plantar common digital
vein; 11, medial plantar metatarsal vein; and
12, cranial branch of the saphenous vein.
functional requirements of areas sustaining high tensional forces com-

pared with pressure-supporting regions. 26
Superficial Digital Flexor Tendon and its

Accessory Ligament
Mechanical Properlies
The SOFT possesses a moderate modulus of elasticity (1096.5 MPa;
mega Pascal: N mm - 2) and a relatively high strength to rupture (average,
1243 daN). The AL-SOFT has moderate strength to rupture (average, 905
daN)9,1O (Crevier, unpublished data, 1993), In the pony hindlimb, the
modulus of elasticity of the SOFT ranges from 1000 MPa to 1282 MPa
and the tendon ruptured at 12.3% strain,44
Function
Weight Bearing and Stance Phase. The SOFT actions are correlated
to active contraction of the muscle belly and to the passive tension of its
accessory ligament. Tension of the AL-SOFT is induced by extension of
the metacarpophalangeal joint when weight is put on the limb. Because
of the eccentric (palmar) position of the SOFT over the proximal scutum,
metacarpophalangeal extension induces a wide distal sliding of the ten-
don (Fig. 35), limited proximally by the AL-SOFT. The AL-SOFT prevents
overstretching of the SOF muscle belly by carrying the load during
metacarpophalangeal overextension,53 especially at the end of a race,
when fatigue weakens the muscle belly. Tension of the whole compo-
nent, between the distal radial insertion and the proximal part of the
middle phalanx insertion, contributes to limit both metacarpophalangeal
and carpal extension. The role of the AL-SOFT has been investigated in
equine cadaver forelimbs under static compression.54 Results showed
that this ligament contributes to the support of the metacarpophalangeal
joint under load. SOFT strains increased significantly after desmotomy
of the AL-SOFT, which has been attributed to the change in the metacar-
pophalangeal joint angle, increasing the moment arm of the SOFT about
this joint. 54 Because of its proximal insertion on the medial humeral
epicondyle, the muscle belly and its fibrous components also limit flexion
of the elbow. Because of the location of the distal insertion on the palmar
aspect of the PIP joint, tension of the SOFT during weight bearing is a
limitation to PIP flexion. Ouring full weight bearing, high tension within
the SOFT (and OOFT) is responsible for stabilization of the PIP joint.
During propulsion, the PIP joint comes into extension and the distal
condyles of the proximal phalanx slide palmarly on the proximal articu-
lar surface of the middle phalanx. Extension and palmar displacement
are limited by the scutum medium, the palmar ligaments, and the SOFT.
The two distal branches of the SOFT inserted on the proximal sides
of the middle phalanx are essential for the stabilization of the PIP joint
304 DENOIX
Figure 35. Isolated specimen placed on a hydraulic press under 1000 OaN used to evaluate
the elongation and displacement of the tendons in the distal forelimb under experimental
conditions that reproduce the stance phase. When pressure was applied on the limb to
obtain a horizontal orientation of the foot , markers were drilled into the tendons at the level
of the horizontal line drawn on the proximal metacarpus; distal markers were drilled 10 cm
below in each tendon. Note that in this limb orientation when high loads are applied, the
distal displacement of the SOFT is pronounced, and the elongation of the TIOM is marked.
The OOFT undergoes the least deformation and distal displacement. Profound alterations
are observed when the limb orientation mimics propulsion. Because of the distal displace·
ment of the SOFT, the AL·SOFT is taut.
in the frontal plane (lateromedial displacements) and the transverse

plane (rotation), especially because of their direct contact with the distal
condyles of the proximal phalanxY
Swing Phase. At the beginning of the swing phase, tension and
elasticity of SOF apparatus contribute passively to initiate flexion of the
carpal, metacarpophalangeal, and PIP joints. Careful examination during
gaits and slow-motion cinematography demonstrates that the SOFT sud-
denly becomes totally relaxed and undergoes vibrations just after the
take-off. Then, flexion of the joints is increased by active muscle belly
contraction, which induces total relaxation of the AL-SOFT. These move-
FUNCTION AL ANATOMY OF TENDONS AND LIGAMENTS IN THE DISTAL LIMBS 305
ments are accompanied by a proximal sliding of the SOFT within the

carpal canal. The respective displacements of the SOFT and palmar an-
nular ligament during the stance phase require further investigations.
Bone Stresses. Extensor tendon tension has been correlated with
bone strain and gait in the walking horse. 4 When high compression is
placed on the radius, the metacarpus and proximal phalanx undergo
high compression on their dorsal cortices and tension on their palmar
cortices. 12 In those circumstances, the flexor tendons contribute promi-
nently to limiting the palmar bending of the bones (Fig. 36), balancing
the stresses on the different aspects of the third metacarpal bone and
proximal phalanx, and preventing fractures.
Deep Digital Flexor Tendon and its

Accessory Ligament
Mechanical Properties
The DDFT possesses a high modulus of elasticity-1585 MPa9 , 10
(Crevier, unpublished data, 1993)-and a considerable strength to rup-
ture (average, 1700 daN). The AL-DDFT has a low modulus of elasticity
(490 MPa) and a moderate strength to rupture (average, 871 daN). In the
pony hindlimb, the modulus of elasticity of the DDFT ranges from 738
to 1398 MPa and the tendon ruptures at 10% strain.42
Function
Weight-Bearing and Stance Phase. Tension of the AL-DDFT facili-
tates carpal extension when load is applied on a limb 12,32 (Fig. 37). For
high loads, the proximal DDFT limits the carpal extension, and the DDF
apparatus limits metacarpophalangeal extension. Because of its proximal
insertion on the medial humeral epicondyle and the fibrous content of
its belly, the deep digital flexor muscle contributes to limit elbow flexion.
The DDFT undergoes mixed stresses in the fetlock area. It supports
tension between its proximal and distal insertions and supports compres-
sion from the proximal scutum, widely applied by the palmar (in terse-
samoidean) ligament on its dorsal aspect. This zone with mixed stresses
has a fibrocartilaginous architecture with a lot of chondrocytes between
the collagenous fibers. In the palmar aspect of the middle phalanx, the
DDFT also has a dorsal fibrocartilaginous pad that supports pressure of
the tuberositas flexoria of the middle phalanx. During DIP flexion (first
parts of the stance phase) the DDFT slides proximally on this bone
surface. During DIP extension (propulsion), because of the presence of
the distal scutum, the DDFT undergoes a relative distal sliding on the
tuberositas flexoria of the middle phalanx. These displacements take
place within the distal recess of the digital sheath.
In the digit, the DDFT facilitates flexion of the PIP joint (in antago-
nism to the SOFT) during weight bearing. Its tension induces axial com-
pression of the articular surfaces within the PIP and DIP joints, and
306 DENOIX
1.......- - - - - 1
n-+-----2
3---------------------r~~
4------------~~
1a
6-----;f1.
Figure 36. Representation of bone orientation and tendon actions of the distal forelimb
under high compression (800 to 1200 DaN). The third metacarpal bone undergoes high
compression dorsally and tension in the palmar cortex. The TIOM and flexor tendons de-
crease the dorsopalmar imbalance of the bone strains. 1, SOFT; 1a, manica flexoria; 2,
OOFT; 3, AL-OOFT; 4, TIOM; 4a, extensor branch of the TIOM; 5, OSL; and 6, dorsal digital
extensor tendon.
balances the tension of the distal part of the dorsal digital extensor
tendon on the dorsal aspect of the phalanges. The DDFT has a prominent
role in stabilization of the DIP joint by orientating the middle phalanx
pressure dorsally on the articular surface of the distal phalanx.
The relationship between the DDFT and the distal sesamoid bone
varies considerably during the stance phase (Fig. 38). During the full
Figure 37. Isolated specimen placed on a hydraulic press under 1000 DaN to evaluate the
functional behavior of tendons and joints of the distal forelimb in experimental conditions that
reproduce the stance phase. Note the spontaneous extension of the carpus when pressure
is applied on the radius.
weight-bearing position, the DDFT is in close contact only with the distal
border of the distal sesamoid bone. During propulsion, the DDFT bends
over the distal scutum and comes in full contact with the distal sesamoid
boneY Abnormal changes in angulation at the tendon insertion may
result in uneven local stress distribution, which could precipitate fail-
ure. 18 The role of the distal scutum is to prevent modifications of fiber
orientation at the distal insertion during flexion and extension move-
ments of the DIP joint46 • 47 (see Fig. 38). Moreover, the distal scutum acts
as a lever to facilitate foot rotation and heel take-off at the end of the
stance phase.
During the last part of the stance phase, the active contraction of the
muscle bellies and the elasticity of the tendon as well as the accessory
ligament have a prominent role in inducing elevation of the fetlock and
propulsion. The DDFT therefore is the most effective agent of DIP joint
extension. It is during this part of the stance phase that the AL-DDFT is
(H
o
00
[ == J Extension during propulsion 1\
I \
I \
. . Flexion during weight bearing / \
I \
'-I ,-,
;'
/ ......... .......
,I ..... __
i
i I
I
I I
I I
I 'I
Figure 38. Role of the distal scutum to prevent modifications of fibers orientation at the distal insertion of the DDFT on
the distal phalanx during flexion and extension movements of the distal interphalangeal joint. 1, DDFT.
FUNCTIONAL ANATOMY OF TENDONS AND LIGAMENTS IN THE mST AL LIMBS 309
stretched maximally 24 and has the most efficient contribution to stabili-

zation of the DIP joint. During propulsion, the increasing angulation of
the DDFT on the distal sesamoid bone makes the pressure progressively
higher on the facies flexoria of this bone. This was supported by a
procedure for computing the internal forces of the digit.3,52 During pro-
pulsion, the proximal border of the sesamoid bone rotates dorsally. PIP
joint extension induces contact between the tuberositas flexoria of the
middle phalanx and the dorsal digital fibrocartilaginous pad of the
DDFT.
Swing Phase. Immediately after take-off, sudden relaxation of the
deep digital flexor apparatus induces vibrations during the swing phase.
At the beginning of the swing phase, tension of the deep digital flexor
apparatus contributes passively to initiate flexion of the interphalangeal,
metacarpal and carpal joints. Then, the flexion of these joints is increased
by active muscle contraction that induces total relaxation of the AL-
DDFT and proximal sliding of the tendon within the digital sheath and
carpal canal.
Suspensory Apparatus (TIOM, Proximal Scutum,

and DSL)
Mechanical Properties
The body of the nOM possesses a relatively high modulus of elas-
ticity (1100 MPa) and considerable strength to rupture (average, 1715
daN). Strain at rupture reaches 10% to 12%9, 10 (Crevier, unpublished
data, 1993). In the pony hindlimb, the modulus of elasticity of the nOM
ranged from 576 MPa to 669 MPa and the tendon ruptured at 11%
strain.44 On isolated anatomic specimens such as the one presented in
Figure 37, the average maximum force applied on the limb to obtain
failure of the suspensory apparatus was 1220 kg (between 918 and 1673
kg) and was significantly higher in trained horses than in resting horses?
Function
The main function of the nOM is to prevent excessive extension
(dorsoflexion) of the metacarpophalangeal joint-i.e., to support the fet-
lock when weight is put on the limb during the standing position or
stance phase (Fig. 39). In the weight-bearing position, tension within the
nOM and flexor tendons regulates the amount and location of the
stresses applied to the different aspects of the third metacarpal bone (see
Fig. 36). For a moderate amount of load, tension within the tendinous
structures on the palmar aspect of the metacarpus induces tension on the
dorsal aspect of the third metacarpal bone and compression within the
palmar cortex. 12 With high compression on the radius, the metacarpus
undergoes high compression on its dorsal cortex and tension on its
palmar cortex. In those circumstances, the nOM and flexor tendons have
310 DENOIX
Figure 39. Dissected specimen placed on a hydraulic press under 300 DaN used to dem-
onstrate the functional behavior of the isolated suspensory apparatus under compression.
Note that the joint angulations are maintained in a physiologic position only by the suspen-
sory apparatus.
a prominent role in limiting the palmar bending of the third metacarpal

bone, balancing the stresses on the different aspects of the bone, and
preventing metacarpal fracturesP
In the full weight-bearing position, the distal part of the nOM
branches are applied closely on the abaxial parts of the metacarpal con-
dyles and act as articular structures. As the fetlock drops, they slide onto
the palmar surface of the condyles. They undergo mixed stresses-ten-
sion that limits sesamoid distodorsal movement and compression in-
duced by the metacarpal condyles palmarly pushed by the articular
surface of the proximal phalanx. During hyperextension of the fetlock,
the proximal sesamoid bones are displaced distally and dorsally, so the
distal branches of the nOM act as articular surfaces to balance the
position of the metacarpal condyles between them and the proximal
phalanx. As the proximal sesamoid bones rotate around the metacarpal
condyle, the fiber orientation at the distal insertion on the interosseous
surface is modified, and the body as well as branches of the nOM

become applied closely to the palmar aspect of the metacarpus, com-
pressing the metacarpal veins. In the weight-bearing position, the exten-
sor branches of the nOM are stretched. Their proximal insertion is made
taut by the tension of the nOM branches and their distal insertion is
pulled by the dorsal digital extensor tendon, which is taut because of
interphalangeal flexion. Elasticity of the nOM contributes to fetlock ele-
vation during propulsion.
During asymmetric load bearing (due to limb obliquity or foot im-
balance), the contribution of the TIOM distal branches and collateral
ligaments to metacarpophalangeal joint stability is higher on the side
opposite the compression (Fig. 40). This asymmetric pressure, combined
with the shape and orientation of the articular surfaces, induces metacar-
pophalangeal rotation on the side opposite to the compressionY
...,...,f----3
Figure 40. Role of the suspensory apparatus in limiting the abaxial movements of the fetlock
during asymmetrical weight bearing. The pressure of the proximal sesamoid bones limits the
transverse sliding of the metacarpophalangeal articular surfaces. The abaxial displacement
and rotation of the digit take place in opposite directions. 1, TIOM distal branch; 2, oblique
sesamoidean ligament; and 3, short sesamoidean ligament.
312 DENOIX
During the swing phase, metacarpophalangeal joint flexion sud-

denly relaxes nOM and, because of the proximal displacement of the
proximal scutum, the branches bend abaxially and separate proximally.
At the beginning of the swing phase and stance phase, sudden modifi-
cations of tension and orientation of fibers induce vibrations within the
nOM.
Because they join the wide distal part of the DDET, the extensor
branches of the nOM are tightened by every interphalangeal flexion.
During the stance phase, they limit the palmar flexion (and the dorsal
subluxation) of the interphalangeal joints because of traction induced
distally by the DDET and proximally by the nOM itself. When the
fetlock drops, the dorsal angle between the distal branch and the exten-
sor branch reduces. Desmopathy with elongation of the superficial part
of the distal branches may induce dorsal subluxation of the PIP joint
because of relaxation of the proximal attachment of the extensor branches
of the nOM. These branches create tension on the dorsolateral and
dorsomedial aspects of the digit, and contribute, with the collateralliga-
ments, to limit movements of rotation and abaxial movements. This
provides interphalangeal stability. During the second part of the swing
phase (protraction), when the fetlock has become extended, the extensor
branches contribute passively to interphalangeal extension.
Distal Sesamoidean Ligaments
The DSLs represent the digital component of the suspensory appa-

ratus, the proximal sesamoid bones and palmar ligament being interca-
lated between the nOM and the DSL. Because of its insertions, the SSL
participates in the sagittal stabilization of the metacarpophalangeal and
PIP joint and has little action on rotation and abaxial movements. Con-
versely, the OSLs have a prominent role in the limitation of rotation and
abaxial movements of the metacarpophalangeal joint when weight is put
on the limb (see Fig. 40). In the weight-bearing position, the OSLs induce
traction on the palmar cortex of the proximal phalanx (see Fig. 36) and
compression on the dorsal aspect. l1 , 12 The SSL and the flexor tendons
limit sagittal deformation of the proximal phalanx.
ROLES OF TENDONS AND LIGAMENTS DURING THE

STANDING POSITION
The horse can remain in a standing position for a long time because
most of the weight is supported by tendons and accessory ligaments,
articular ligaments, fibrous intersections within the muscle bellies, and
fascias.
Elbow
The bellies of the caudal antebrachial muscles contain a large quan-
tity of tendinous tissue. Their proximal insertions are on the humeral
epicondyles, caudal to the axis of rotation of the humeroantebrachial

joint. 50 In the standing position, suspension of the fetlock induces distal
traction on the tendons. The continuing tendinous intersections in the
digital flexor muscles are tense and therefore prevent flexion of the elbow
joint. The triceps brachii and the coupled action of the ascendant pectoral
and brachiocephalicus muscles also assist in preventing flexion of the
humeroantebrachial joint.
Carpus
In a standing position, because of the shape of the distal articular

surface of the radius with condylar facets located palmad, the carpus is
spontaneously in extension without any muscle action. This is demon-
strated on isolated limbs (see Fig. 37), with sections of all the extensor
and flexor muscles placed under compressionY Extension also is par-
tially due to the palmarodistal traction of the AL-DDF tendon and
TIOM.J2, 32 Under clinical conditions, elongation of the AL-DDF tendon
or TIOM often is accompanied by a lack of carpal extension and the knee
deviates forward (the horse becomes buck kneed). Overextension is pre-
vented by the palmar wall of the carpal canal (see Fig. 9) and accessory
carpal bone ligaments, as well as the strong common palmar ligament
caudally, and by close packing of the bearing facets of the carpal bones
dorsally. Overextension also is limited by the tension of the flexor ten-
dons and AL-SDFT. The extensor carpal radialis inserts on a large dor-
somedial tubercle on the proximal metacarpus and has a passive exten-
sion action because of its relationship with the biceps brachii via the
lacertus fibrosis, The biceps brachii is tensed in the standing horse, be-
cause of its action to prevent collapse of the shoulder joint.
Fetlock
The distal parts of the flexor tendons passively limit overextension

of the metacarpophalangeal angle during weight bearing because of their
proximal attachments to bone by their accessory ligaments. The suspen-
sory apparatus, comprising the TIOM, proximal sesamoid bones, palmar
ligament, and DSL, has a prominent role in the prevention of overexten-
sion or collapse of this joint. All these elements are tensed under load.
Under pathologic conditions, section, rupture, or elongation of one of
these components induces a lack of suspension of the fetlock Overexten-
sion of the fetlock joint also is limited by the deep palmar part of the
collateral ligaments of the joint. High dorsal traction induced by the
distal and extensor branches of the TIOM on the abaxial (interosseous)
face of the distal sesamoid bones (see Fig. 36) is balanced by two struc-
tures-the strong palmar (intersesamoidean) ligament and the palmar
annular ligament. This must be considered in the pathogenesis of palmar
annular ligament desmopathy.
314 DENOIX
Modification of the foot or limb position induces asymmetric strain

within the distal branches of the nOM and OSL. Stresses in elongation
are higher on the opposite side of the compression, limit displacements
in the frontal plane, and contribute to rotation (see Fig. 40). The proximal
scutum is displaced toward the side of compression, and the contact
between the sagittal ridge of the metacarpal condyle and the correspond-
ing proximal sesamoid bone prevents the articular surfaces from sliding
transversely (see Fig. 40).
PIP Joint
At rest or during the stance phase, flexion of the PIP joint is pre-
vented by the SDFT, which inserts on the abaxial parts of the thick
scutum medium. Tension of the oblique and straight sesamoidean liga-
ments and extensor branches of the nOM also limits the flexion (col-
lapse) of the PIP joint.12. 13 When weight is put on the limb, all these
anatomic elements are under tension and pull back on the PIP joint.
Clinically, relaxation of the distal sesamoidean ligaments induced by
rupture or elongation of the nOM is accompanied by a lack of extension
(dorsal subluxation and flexion) of the PIP joint. Flexion of the PIP joint
also is limited by the DDET tendon, which inserts on the dorsal aspect
of the proximal phalanx and on the extensor process of the middle
phalanx (see Fig. 26). The collateral sesamoidean ligaments inserted on
the distal end of the abaxial aspect of the proximal phalanx, as well as
collateral ligaments of the PIP joint, also limit PIP joint flexion.
Extension of the PIP joint is controlled by the DDFT and the palmar
(axial and abaxial) ligaments of the joint. Overextension of this joint also
is prevented by the straight sesamoidean ligament (if the nOM is taut)
and the SDFT. During the stance phase and propulsion, the SDFT acts
on the PIP joint as an extensor, a role opposite to its function during the
swing phase. In combination with the collateral and palmar ligaments,
the distal branches of the SDFT and the extensor branches of the nOM
contribute to the stabilization of the PIP joint in the frontal plane. Modi-
fications of the foot or limb position induce asymmetric passive strains
within these elements that limit passive movements of abduction and
adduction. Stresses in elongation are higher on the side opposite the
compression, limit displacements in the frontal plane, and contribute to
rotation. The middle scutum acts as the proximal scutum for the meta-
carpophalangeal joint. The extensor branches of the nOM also limit
rotation between the proximal and middle phalanges.
DIP Joint
Stabilization of the DIP joint is the result of a complex balance of

tensions. Flexion (collapse) of the joint is prevented by the stabilization
of the fetlock. It also is limited by the wide dorsal digital extensor ten-
don, strongly attached on the dorsal aspect of the middle phalanx and
on the extensor process of the distal phalanx (see Fig. 36). This system is
reinforced by the extensor branches of the nOM. During full weight
bearing, when the pastern is almost horizontal, the distal part of the
DDET gets a large area of contact with the dorsal part of the distal
articular surface of the middle phalanx and acts as an articular structure.
The collateral ligaments of the joint also contribute to limiting DIP joint
flexion. Conversely, distal interphalangeal flexion induces relaxation of
the collateral and distal sesamoidean ligaments.
At the palmar aspect of the joint, in the weight-bearing position,
tension of the DDFT has a prominent role in maintaining a horizontal
orientation of the foot and preventing palmar subluxation of the middle
phalanx. Experimental studies performed on isolated limbs12- 14 demon-
strated that desmotomy of the AL-DDFT induces instability of the DIP
joint, with disparity of contact between the articular surfaces of the
middle and distal phalanges dorsally. Similar results were obtained with
tenotomy of the DDFT. Clinical cases also demonstrate that rupture or
elongation of the DDFT induces DIP joint instability and, in more severe
cases, a functional inability to control the orientation of the foot during
landing and to maintain a horizontal orientation of the foot during
weight bearing. The tension generated within the tendons is parallel to
the pastern axis. In the dynamic weight-bearing position, the pastern
orientation is oblique, and experimental simulations on isolated limbs
suggest that forces exerted by the middle phalanx on the articular surface
of the distal phalanx are orientated dorsodistally during mid-stance,
although the weight force component is vertical.
During propulsion, extension of the DIP joint accompanies fetlock
elevation, bringing the pastern vertical. It also is induced directly by the
tension of the DDFT, the role of which becomes opposite its function
during the swing phase. Extension of the DIP joint induces traction in
the collateral and distal sesamoidean ligaments of the joint, which con-
tributes to limiting the movement. Pressure between the DDFT and the
distal sesamoid bone increases4 because of the inflexion of the tendon on
the distal scutum.
The collateral ligaments and collateral sesamoidean ligaments, the
distal expansion of the DDFT palmarly, and the DDET, as well as the
extensor branches of the nOM dorsally, contribute to the stabilization of
the DIP joint in the frontal plane and limit passive movements of abduc-
tion and adduction. All these anatomic structures also limit DIP joint
rotation. Modifications of the foot or limb position induce asymmetric
strains within the distal parts of the DDFT and DDET, as well as collat-
eral and collateral sesamoidean ligaments. Stresses in elongation are
higher on the side opposite the compression, limit displacements in the
frontal plane, and contribute to rotation. Desmotomy of the collateral
sesamoidean ligaments on isolated limbs induces DIP joint instability
during propulsion or an asymmetric weight-bearing position. 12- 14
316 DENOIX
CHRONOLOGIC INTERVENTION OF THE TENDONS

DURING THE STANCE PHASE AND MODIFICATIONS
INDUCED BY TOE OR HEEL ELEVATION
Tendon Behavior During the Stance Phase
The functional anatomy of equine tendons and joints of the distal

limbs was investigated a long time ago on isolated specimens placed
under 10ad.58 Recent investigations have been performed under in vitro
or in vivo experimental conditions, which have contributed to a better
knowledge of the functional behavior of equine tendons,49 but a lot of
data still are lacking for a complete understanding under all physiologic
conditions of locomotion and sport exercises.
Just before landing, the correct orientation of the foot is controlled
by the DDFT, which induces a distal interphalangeal joint flexion (Fig.
41A) to restore horizontal placement of the foot at the end of the swing
phase. During this action, the dorsal and lateral digital extensor tendons
maintain fetlock extension. On the SDFT of a pony at walk, muscle
activity was recorded just preceding the foot's contact with the ground. 55
This muscle contraction may tense the tendon before application of high
loads to prevent sudden elongation and vibrations of the tendon. 49
The sudden hoof impact during landing leads to vibrations. These
vibrations are limited by the palmar metacarpal fascia and annular liga-
ments, as well as by active muscle contraction, pre-stiffening the flexor
tendons, and removing laxity from the joints.
During mid-stance (Fig. 41B), fetlock extension induces high tension
in the SDFT and its accessory ligament. The whole suspensory apparatus
undergoes high stresses: The fetlock extension induces high strains on
the nOM, sesamoid bones, and distal sesamoidean ligaments. The DIP
flexion is limited by tension of the distal part of the DDET and extensor
branches of the nOM, which contribute to stabilize the PIP joint. Al-
though it makes an important contribution to interphalangeal stability
and fetlock suspension, the DDFT and its accessory ligament are rela-
tively less stressed than the nOM and SDFT, because of the DIP joint
flexion.
During the last period of the stance phase (Fig. 41C, propulsion),
which brings the pastern vertical, fetlock elevation (metacarpophalangeal
flexion) is induced by the passive elastic behavior of the suspensory
apparatus, flexor tendons, and accessory ligaments, which are strongly
elongated during the preceding mid-stance phase. Additional active con-
tribution is provided by muscle contraction of the digital flexor muscle
bellies. At the end of propulsion, fetlock flexion is accompanied by a
relaxation of the suspensory apparatus. Because of the proximal displace-
ment of the proximal sesamoid bones, the nOM becomes relaxed. The
DIP joint extension induces relaxation of the extensor branches of the
nOM. Fetlock flexion also induces an SDFT proximal displacement, in-
ducing AL-SDFT relaxation. Tension within the SDFT is maintained by
the muscle belly's active contraction. The DDFT makes a prominent
contribution to the propulsion period of the stance phase. Before heel
§l High tension o Moderate tension
A B c
Figure 41. Functional anatomy of the TIOM , flexor tendons, and accessory ligaments during the stance phase. A, Propulsion; a,
mid-stance phase; C, landing. For more complete explanations, see text.
<J>
......
~
318 DENOIX
take-off, the DIP extension maintains tension within the AL-DDFT and
the distal part of the DDFT. At the end of the movement, this passive
tension and the added traction of the muscle belly are responsible for
heel take-off and the DIP flexion.
In vivo tendon forces were evaluated in the forelimb of ponies at
the walk. 24 During the first part of the stance phase, forces peaked in the
SDFT and DDFT and, in some individuals, in the nOM. The AL-DDFT
was loaded during the second part of the stance phase. The total load
was higher for the TIOM and AL-DDFT than for the flexor tendons. 24
In vivo tension strain recorded during normal walking in the hind-
limb of ponies demonstrated peaks of tension within the SDFT and
nOM during the first half of the stance phase and peak tension within
the DDFT and nOM during the second half of the stance phaseY, 45 It
must be noted that the SDF muscle belly is reduced in the hindlimb, so
the active traction on the tendon is limited during propulsion. Moreover,
joint angle functional association by the reciprocal apparatus may induce
differences compared with the similar musculotendinous structures of
the forelimb. Measurements of nOM surface strains on horse forelimbs
while walking28 were in agreement with the previous studt2 and indi-
cated a biphasic peak of strain during the stance phase.
Continuous measurements of in vivo tendon strains in the forelimb
SDFT of horses demonstrated the same kind of strain curve as in the
hindlimb at the walk, but strain pattern changed between the walk and
faster gaits. 57 At the trot and gallop, the peak of the strain curve is higher
and occurs near the mid-stance phase.
The load curve of an SDFT at the gallop was approximated using
postmortem specimens placed on a testing machine.49 The conclusion of
this in vitro study were consistent with in vivo strain investigations that
demonstrated the prominence of the passive action of the flexor tendons
with their accessory ligaments and suspensory apparatus during weight
bearing.
Modifications Induced by Toe or Heel Elevation
Under static conditions, on live horses as well as on isolated limbs,

modifications of the foot orientation in the sagittal plane induce distal
joint displacements and rearrange the tensions within the flexor tendons
and suspensory apparatusY, 12, 25, 31, 32, 36, 38, 48, 60
Elevation of the heel (Fig. 42A) provokes DIP joint flexion, inducing
partial relaxation of the DDFT.8, 11, 12,25,32,60 The contribution of this tendon
to fetlock suspension therefore decreases and the joint extends. This
extension is responsible for a greater participation of the suspensory
apparatusl l , 12, 29, 60 in fetlock suspension. Evaluation of nOM strain at the
walk with hoof-wall-angle manipulation demonstrates that the nOM
strain is positively correlated with a hoof-wall angle of up to 65 degrees29
and the main increase in nOM strain per 10 degrees of hoof wall in-
crease was 0.6%.29 Although it has not been established clearly, a positive
r R
A B
Figure 42. Modifications of the amount of tension within the TIOM and flexor tendons
induced by elevation of the heels (A) or elevation of the toe (8).
correlation between the hoof angle and the SDFT apparatus strain is
suspected. 11 , 12 In the standing horse, elevating the heel by 10 degrees
may change the fetlock angle by only 1 degree. 61 Another studt indi-
cated that a I-degree increase in hoof angle decreases the metacarpopha-
langeal joint angle 0.13 degree. An increase in hoof angle also releases
tension on the collateral sesamoidean ligaments and is accompanied by
PIP joint flexion. 8, 12-14
Elevation of the toe (Fig. 42B) provokes DIP extension, inducing an
increasing traction on the DDFT and its accessory ligament. II , 12, 25, 32, 48 The
pastern becomes more vertical and the fetlock elevated, and the participa-
tion of the TIOM and SDFT in fetlock suspension is decreased.11 , 12, 32
In vivo, measurement of tendon strains on adult horses in the stand-
ing position and while walking demonstrated that there was a decrease
in strain for the DDFT with increases in hoof angle, but no appreciable
change in strain for the SDFT and TIOM with changing hoof angle
between 40 degrees and 70 degrees?3 In another study,57 in vivo contin-
uous recording of forelimb SDFT strains showed that manipulation of
the hoof angle by raising the heels by 5 to 10 degrees did not alter SDFT
strains at the walk, but resulted in relative increases in weight-bearing
SDFT strains at the trot. 57 Conversely, elevation of the toe resulted in a
small decrease in the magnitude of change in strain during weight bear-
ing in the SDFT at the walk and the trot. S7
320 DENOIX
ACKNOWLEDGMENTS
Many thanks to Patricia Perrot and Benoit Bousseau for their help in the preparation
of the manuscript.
References
1. Barone R: Anatomie Comparee des Mammiferes Domestiques, Tome 2: Arthrologie et

Myologie, ed 2. Paris, Vigot, 1980, pp 187-217
2. Barone R: Anatomie Comparee des Mammiferes Domestiques, Tome I: Osteologie, ed
3. Paris, Vigot, 1986, p 296
3. Barnes GRG, Pinder ON: In vivo tendon tension and bone strain measurement and
correlation. J Biomech 7:35-42, 1974
4. Bartel DL, Schryver HF, Lowe JE, et al: Locomotion in the horse: A procedure for
computing the internal forces in the digit. Am J Vet Res 39:1721-1727,1978
5. Bouley MH: Traite du pied du cheval. In Labe (ed): Atlas. Paris, 1851, p 34
6. Bramlage LR: Superior check desmotomy as a treatment for superficial digital flexor
tendonitis: Initial report. Proc Am Assoc Equine Pract 33:365-369, 1987
7. Bukowiecki CF, Bramlage LR, Gabel AA: In vitro strength of the suspensory apparatus
in training and resting horses. Vet Surg 16:126-130, 1987
8. Bushe T, Turner TA, Poulos PW, et al: The effect of hoof angle on coffin, pastern and
fetlock joint angles. Proc Am Assoc Equine Pract 33:729-738,1988
9. Crevier N: Etude du comportement des tendons de la main du cheval soumis a des
contraintes en elongation. Memoire de DEA de Biomecanique et Physiologie du Mouve-
ment; Universite de Paris Sud, 1990
10. Crevier N, Pourcelot P, Denoix JM, et al: Comparative analysis of mechanical behavior
and histology of the three palmar tendons of the horse hand. In Proceedings of the
Congress of the International Society of Biomechanics, Paris, France, 1993, pp 292-293
11. Denoix JM: Biomecanique de la region phalangienne chez Ie cheval. CEREOPA-ERPC,
Proceedings, 11 eme Journee d'Etudes, 1985, pp 60-75
12. Denoix JM: Etude biomecanique de la main du cheval: Extensometrie des rayons
metacarpo-phalangiens et surfaces articulaires de contact (These de Doctorat). Univer-
site Claude Bernard, Lyon I, 1987, P 565
13. Denoix JM, Berthelet MA: Etude biomecanique des articulations interphalangiennes du
Cheval par la methode des surfaces de contact. CEREOPA-ERPC, Proceedings 13e me
Journee d'Etude, 1987, pp 145-164
14. Denoix JM, Berthelet MA: Biomechanical approach of the distal sesamoid bone with a
new method of contact study. In Proceedings of the International Congress on Equine
Surgery and Equestrian Sports Medicine. Geneve, Swiss Equine Medical Association,
1987, pp 62-85
15. Dyce KM, Sack WO, Wensing CJG: Textbook of Veterinary Anatomy. Philadelphia, WB
Saunders, 1987, pp 566-567
16. Ellenberger W, Baum M: Handbuch der Vergleichenden Anatomie der Haustiere, ed
13. Berlin, Verlog Von August Mirschwald, 1912, pp 158-163
17. Emery L, Miller J, Van Hoosen N: Horseshoeing Theory and Hoof Care. Philadelphia,
Lea & Febiger, 1977, pp 39-63
18. Evans JH, Barbenel JC: Structural and mechanical properties of tendon related to
function. Equine Vet J 7:1-8, 1975
19. Getty R: Sisson and Grossman's: The anatomy of domestic animals, ed 5. Philadelphia,
WB Saunders, 1975, pp 358-362
20. Hago BED, Vaughan LC: Radiographic anatomy of the tendon sheaths and bursae in
the horse. Equine Vet J 18:102-106, 1986
21. Hay-Kraus BL, Kirker-Head CA, Jakowski R, et al: The vascular anatomy of the equine
deep digital flexor tendon [abstract 541. Vet Surg 21:395-396, 1992
22. International Committee on Veterinary Gross Anatomical Nomenclature: Nomina An-
atomica Veterinaria, ed 3. Ithaca, NY, World Association of Veterinary Anatomists,
1983, p 37
23. Jann HW, Beroza GA, Fackelman GE: Surgical anatomy for desmotomy of the accessory
ligament of the superficial digital flexor (proximal check ligament) in horses. Vet Surg
15:378-382,1986
24. Janssen MO, Van den Bogert AJ, Riemersma DJ, et al: In vivo tendon forces in the
forelimb of ponies at the walk, validated by ground reaction force measurements. Acta
Anat 146:162-167,1993
25. Joly G, Tasset: Observations sur Ie travail des tendons flechisseurs du pied du cheval.
Rev Gen Med Vet, vol IX:253-255, 1907
26. Jones AJ, Bee JA: Age- and position-related heterogeneity of equine tendon extracellular
matrix composition. Res Vet Sci 48:357-364, 1990
27. Kainer RA: Functional anatomy of equine locomotor organs. In Stashak TS (ed): Adam's
Lameness in Horses, ed 4. Philadelphia, Lea & Febiger, 1987, pp 1-70
28. Keegan KG, Baker GJ, Boero MJ, et al: Evaluation of support bandaging during meas-
urement of proximal sesamoidean ligament strain in horses by use of a mercury strain
gauge. Am J Vet Res 53:1203-1208, 1992
29. Keegan KG, Baker GJ, Boero MJ, et al: Measurement of suspensory ligament strain
using a liquid mercury strain gauge: Evaluation of strain reduction by support bandag-
ing and alteration of hoof wall angle. Proc Am Assoc Equine Pract 37:243-244,1991
30. Kraus-Hansen AE, Fackelman GE, Becker C, et al: Preliminary studies on the vascular
anatomy of the equine superficial digital flexor tendon. Equine Vet J 24:46-51, 1992
31. Leach DH: Biomechanical considerations in raising and lowering the heel. Proc Am
Assoc Equine Pract 29:333-342, 1983
32. Lienaux, Zwaenepoel: A propos d'une etude sur Ie mecanisme passif de la station chez
Ie Cheval. Contribution a la physiologie des tendons flechisseurs du pied. Ann Med
Vet 58:65-78, 1909
33. Lochner FK, Milne OW, Mills EJ, et al: In vivo and in vitro measurement of tendon
strain in the horse. Am J Vet Res 41:1929-1937,1980
34. McIlwraith CW: Diseases of joints, tendons, ligaments, and related structures. In Stas-
hak TS (ed): Adam's lameness in horses, ed 4. Philadelphia, Lea & Febiger, 1987, pp
339-485
35. Montane L, Bourdelle E: Anatomie regionale des animaux domestiques. In Bailliere
(ed): vol 1, Paris, 1913, pp 662-709
36. Moyer W, Raker CW: Diseases of the suspensory apparatus. Vet Clin North Am Large
Anim Pract 2(1):61-80, 1980
37. Nickel R, Schummer A, Seiferle E: Lehrbuch der Anatomie der haustiere, Band 1. Berlin
und Hamburg, Verlag Paul Darcy, 1977, pp 213-215
38. Pader J: Precis theorique et pratique de marechalerie. Carre G (ed): Paris, 1892, p 393
39. Resnick D, Niwayama G: Diagnostic radiology. Entheses and Enthesopathy. Radiology
146:1-9,1983
40. Resnick D, Niwayama G: Supporting structures. In Diagnosis of Bone and Joint Disor-
ders, ed 2, vol 2. Philadelphia, WB Saunders, 1988, pp 644-645
41. Resnick D, Niwayama G: Trauma to supporting structures, syndesmoses, and entheses.
In Diagnosis of Bone and Joint Disorders, ed 2, vol 5. Philadelphia WB Saunders, 1988,
pp 2974-2977
42. Riemersma OJ: Kinetics and kinematics of the equine hind limb: In vivo tendon strain
and joint kinematics. Am J Vet Res 49:1353-1359, 1988
43. Riemersma OJ, De Bruyn P: Variations in cross-sectional area and composition of
equine tendons with regard to their mechanical function. Res Vet Sci 41:7-13,1986
44. Riemersma DJ, Schamhardt HC: In vitro mechanical properties of equine tendons in
relation to cross-sectional area and collagen content. Res Vet Sci 39:263-270, 1985
45. Riemersma OJ, Schamhardt HC, Hartman W, et al: Kinetics and kinematics of the
equine hind limb: In vivo tendon loads and force plate measurements in ponies. Am J
Vet Res 49:1344-1352,1988
46. Rooney JR: Biomechanics of Lameness in Horses. Baltimore, Williams & Wilkins, 1969
47. Rooney JR: The Lame Horse. Causes, Symptoms and Treatment. New York, Millwool,
1974, P 237
48. Rooney JR: The angulation of the forefoot and pastern of the horse. J Equine Vet Sci
4:138-143,1984
49. Rooney JR, Quddus MA, Kingsbury HB: A laboratory investigation of the function of
the stay apparatus of the equine foreleg. J Equine Med Surg 2:173-180,1978
322 DENOIX
50. Sack WO: Guide to Dissection of the Horse. Ithaca, NY, Veterinary Text Books, 1977
51. Schmaltz R: Atlas der Anatomie des Pferdes, teil2. Berlin, Schoetz, 1909, pp 36-40
52. Schryver HF, Bartel DL, Langrana N, et al: Locomotion in the horse: Kinematics and
external and internal forces in the normal equine digit in the walk and trot. Am J Vet
Res 39:1728-1733, 1978
53. Shively MJ: Functional and clinical significance of the check ligaments. Equine Pract
5:37-42, 1983
54. Shoemaker RS, Bertone AL, Mohammad LN, et al: Desmotomy of the accessory liga-
ment of the superficial digital flexor muscle in equine cadaver limbs. Vet Surg 20:245-
252, 1991
55. Silver IA, Brown PN, Goodship AE: Biomechanical assessment of locomotor perform-
ance in the horse. In Silver IA and Rossdale PO (eds): A clinical and experimental study
of tendon injury, healing and treatment in the horse. Equine Vet J (suppl):23-35, 1983
56. Spaulding K: Ultrasonic anatomy of the tendons and ligaments in the distal metacarpal-
metatarsal region of the equine limb. Vet RadioI25:155-166, 1984
57. Stephens PR, Nunamaker OM, Butterweck OM: Application of a Hall-effect transducer
for measurement of tendon strains in horses. Am J Vet Res 50:1089-1095,1989
58. Straunard R: Les efforts des tendons. Ann Med Vet 84:49-67,1939
59. Stromberg B, Tufvesson G: Lesions of the superficial flexor tendon in race horses: A
microangiographic and histopathologic study. Clin Orthop 62:113-123,1969
60. Thompson KN, Cheung TK, Silverman BS: The influence of toe angle on strain charac-
teristics of the deep digital flexor tendon, superficial flexor tendon, suspensory liga-
ment, and hoof wall. Equine Athlete 5:1-7, 1992
61. Turner TA, Poulos PW, Harwell NM: The effect of hoof angle on coffin, pastern and
fetlock joint angles. Proc Am Assoc Equine Pract 33:729-738,1987
62. Webbon PM: A histological study of macroscopically normal equine digital flexor
tendons. Equine Vet J 10:253-259, 1978
63. Wilson DA, Baker GJ, Pijanowski GJ, et al: Composition and morphologic features of
the interosseous muscle in Standardbreds and Thoroughbreds. Am J Vet Res 52:133-
139, 1991
Address reprint requests to

Jean-Marie Denoix, DVM, PhD
Clinique Equine
Ecole Nationale Veterinaire d'Alfort
7, Avenue du General de Gaulle
94704 Maisons-Alfort
Cedex, France

Functional Anatomy of Tendons and Ligaments in The Distal Limbs (Manus and Pes)

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Functional Anatomy of Tendons and Ligaments in The Distal Limbs (Manus and Pes)

Uploaded by

Copyright:

Available Formats

TENDON AND LIGAMENT INJURIES: PART I 0749-0739/94 $0.00 + .

VETERINARY CLINICS OF NORTH AMERICA: EQUINE PRACTICE

VOLUME 10 • NUMBER 2' AUGUST 1994 273

ments to bone (entheses) are of particular interesr9 , 4o and require further

Superficial Digital Flexor Tendon and its Accessory

The body of the superficial digital flexor muscle is attached proxi-

called radial, proximal, or superior check ligament,53 courses distocaudally

Figure 5. Palmomedial aspect of the

Deep Digital Flexor Tendon and its Accessory

Third Interosseous Muscle and Distal

in their TIOM than Thoroughbreds (14% versus 10% of total area).93

9 mm thick, and wider proximally than distally (Fig. 8). Proximally, it

Figure 8. Palmar aspect of the digit.

The palmar wall of the digital sheath is composed of two annular

Figure 10. Palmaromedial aspect of the

Figure 12. Oorsopalmar contrast radio-

mopalmar recess of the distal interphalangeal (DIP) joint. At the

The podotrochlear bursa (navicular bursa) is between the DDFT and

Vessels and Nerves

Figure 13. Palmar aspect of the digit. 1,

Figure 14. Palmar aspect of the distal

The metacarpal part of the flexor tendons is supplied by the palmar

TOPOGRAPHIC ANATOMY AND CROSS-SECTIONS

The shape and relationships of the anatomic structures of the pastern

Proximal Part of the Proximal Phalanx

The palmar (metacarpophalangeal) annular ligament lies immedi-

Middle Part of the Proximal Phalanx

Figure 19. Transverse cross-section of

Figure 20. Transverse cross-section in the

Figure 21. Transverse cross-section in the

Figure 22. Sagittal section of the meta-

Figure 23. Transverse section of the meta-

Figure 24. Transverse section of the

Distal Part of the Proximal Phalanx

At this level, the synovial membrane is separated from the skin by a

Figure 30. Frontal section of the digit

Proximal Interphalangeal Joint and Proximal Part of the

The palmar surface of the distal digital annular ligament is widely

The anatomy in the metatarsus is different from that in the metacar-

MECHANICAL PROPERTIES AND FUNCTIONAL

Tendons and ligaments have several important roles during loco-

load-bearing collagen, glycosaminoglycans, and cells, is due to functions

Figure 34. Transverse cross·section in the

functional requirements of areas sustaining high tensional forces com-

Superficial Digital Flexor Tendon and its

in the frontal plane (lateromedial displacements) and the transverse

ments are accompanied by a proximal sliding of the SOFT within the

Deep Digital Flexor Tendon and its

stretched maximally 24 and has the most efficient contribution to stabili-

Suspensory Apparatus (TIOM, Proximal Scutum,

a prominent role in limiting the palmar bending of the third metacarpal

surface is modified, and the body as well as branches of the nOM

During the swing phase, metacarpophalangeal joint flexion sud-

Distal Sesamoidean Ligaments

The DSLs represent the digital component of the suspensory appa-

ROLES OF TENDONS AND LIGAMENTS DURING THE

epicondyles, caudal to the axis of rotation of the humeroantebrachial

In a standing position, because of the shape of the distal articular

The distal parts of the flexor tendons passively limit overextension

Modification of the foot or limb position induces asymmetric strain

Stabilization of the DIP joint is the result of a complex balance of

CHRONOLOGIC INTERVENTION OF THE TENDONS