Many equine practitioners will encounter horses experiencing some degree of back pain, especially if their practice treats performance horses. In this episode of the Disease Du Jour podcast, Christopher Elliott, BVSC, MRCVS, MANZCVS, DACVSMR, of Palm Beach Equine Clinic, joined us to talk about diagnosing, treating and rehabilitating horses with back pain.
Clinical Signs of Back Pain in Horses
Elliott started by describing some of the clinical signs of back pain in horses, which often include generalized poor performance or palpation abnormalities.
“Back issues are typically associated with movement problems and performance problems. They are not typically associated with either asymmetry or obvious lameness type issues,” he said.
In sporthorses, poor performance might manifest as difficulties in the canter or trot, trouble with lateral work for dressage horses, or leaving rails down for jumpers.
Physical Examination for Horses with Suspected Back Pain
When examining the back, Elliott noted that “it’s important to remember that it’s one spine, from head to tail, and they’re all interrelated.” Therefore, as part of a thorough orthopedic exam, practitioners should always be palpating the back, whether they are primarily thinking about the axial skeleton or the limbs.
Elliott starts by palpating at the midline with firm pressure. He then presses through the epaxial muscles on either side of the midline and palpates all the way through the pelvic region. He also palpates and examines flexibility through the neck. While palpating, he feels for any change of muscle tone or asymmetry. He also watches for any pain response from the horse. During the static exam, he also palpates all four legs.
Next, Elliott watches the horse move in hand at the walk and trot, both from behind and from the side. He looks at how the back moves and watches for any asymmetry of movement. If possible, he also watches the horse trot on a hard circle, ideally on a lunge. Next, he watches the horse move under saddle and asks the rider to try to replicate some of the movements that the horse has been finding difficult.
In the podcast, Elliott also briefly discussed nerve blocking in backs, which is not always appropriate but might be useful in a limited number of cases.
Elliott said that diagnostic imaging for backs typically starts with digital radiography. “Radiographing the dorsal spinous processes of the back is now quite easily achieved in the field and quite reliably achieved with relatively good image quality,” he said.
However, Elliott noted that multiple studies have noted a poor correlation between radiographic abnormalities of the dorsal spinous processes and pain. Therefore, radiographs of the dorsal spinous processes cannot be relied on too heavily.
Elliott said that ideally, a comprehensive radiographic examination of the back will also include radiographs of the articular facets and the vertebral bodies, which can be very difficult if not impossible in the field due to the amount of power and the size of the plates those images require. Horses will often need to be radiographed in the clinic.
Ultrasonography is another useful tool for diagnosing back pain, allowing the practitioner to look at the muscles, ligaments and soft tissues of the back. Ultrasonography can also be used to look at the articular facets.
The next diagnostic modality is scintigraphy, which Elliott said can be extremely helpful in identifying areas that can’t be imaged any other way. However, he noted that it can sometimes be misleading in chronic cases, as the affected regions might not currently be metabolically active.
“Each of the modalities have their pros and cons,” said Elliott. “When you put them all together, it’s extremely helpful to give you a good story.”
Common Diagnoses in Horses with Back Pain
According to Elliott, the most common and “classic” diagnosis for horses with primary back pain is the impingement or overriding of the dorsal spinous processes, also known as kissing spines. Another potential diagnosis is arthritic changes associated with the articular facets, which Elliott said “is probably something that we don’t recognize enough.”
A more unusual diagnosis is ventral spondylosis, or bridging of the ventral aspect of the vertebral bodies. “We’re starting to recognize those a little more at times, but it’s difficult to know their significance,” Elliott said.
Back pain could also be the result of soft tissue pain or primary muscle pain. It could be related to external factors, such as poor saddle fit, lack of strength and conditioning through the back, or poor riding technique. Sometimes, horses can have a sore back without an identifiable cause.
“When it comes to backs, we have a bit of a vicious cycle at times,” said Elliott. “We have a primary cause that’s potentially resulting in pain. We have associated potential muscle spasm, and then we have guarding and bracing of the back by the horse to protect it. That leads to the back not being used appropriately.” When the back isn’t used properly, it can lead to atrophy, lack of ability to support the back and more pain.
Elliott said that veterinarians are sometimes coming in well beyond the beginning of this cycle, which means they may never be able to give an exact diagnosis. In those cases, they will institute treatments and management practices to try to stop the pain-spasm-misuse cycle and get the horse back on track. Elliott said that these problems are typically performance-limiting and not usually career-limiting.
Treatment Options for Horses with Back Pain
In terms of treating horses with back pain, Elliott noted that “it’s awfully easy to spend clients’ money extremely quickly.” Therefore, practitioners often have to think about how best to stop the pain-spasm-misuse cycle to make subsequent rehab and training more effective.
Elliott said that treatments can be grouped into different categories: systemic medical treatment, targeted medical treatment, alternative therapies and manual therapies.
Systemic medical management can involve non-steroidal anti-inflammatories or muscle relaxants, which can help get the horse through the acute phase and into the rehabilitative management phase.
Targeted therapies, depending on the diagnosis, can include injectable steroids, which can be placed between dorsal spinous processes, close to the articular facets or along multiple areas of the epaxial muscles. Ultrasound can help to provide more accurate placement of needles in these cases. Non-steroid options for targeted treatment include blood-derived biologics such as platelet-rich plasma (PRP).
Alternative therapies include acupuncture, which Elliott said can be very effective in the back when used in conjunction with other therapies, especially in horses competing in sports with medication rules. Mesotherapy is another alternative therapy that Elliott finds useful; this therapy can be applied drug-free or with medication.
Non-needle options for managing back pain include shockwave, which provides an analgesic component to the back. Class 3 or Class 4 lasers can also provide an analgesic component to a certain extent.
Manual therapies for backs include massage manipulation exercises and targeted movement stimulation from licensed and qualified veterinary physiotherapists and qualified veterinary chiropractors.
“Everything in backs requires multiple modalities,” Elliott noted.
Rehabilitation and Exercise
According to Elliott, exercise, rehabilitation and management are key for horses with back issues. The point of veterinary management is to stop the acute pain so the horse can begin the rehabilitation process.
Elliott said that strength and conditioning of the back involves good quality riding, consistent riding and performing exercises to engage the core muscles, such as “tummy tucks” achieved by pressing upwards at the back of the horse’s sternum for 30 seconds and three repetitions. Pelvic tucks and carrot stretches are also useful exercises.
For exercise, Elliott often recommends that his clients lunge with the Pessoa system or utilize therabands that go around the haunches to help engage the core. Good quality flatwork and cross training are also key to managing a horse with a sore back. Walking the horse backwards on the ground, or practicing square halts into rein backs undersaddle, are good ways to strengthen the muscles through the hindquarters. Elliott also recommended finding a dressage rider to school the horse every week.
A simple trick he recommended was physically warming the back before exercise using hot packs. He also suggested icing the back after exercise to get rid of acute inflammation.
“I think probably the best summary of managing backs is that it needs to be multimodal,” said Elliott. “Each horse will be an individual, and each client will be an individual. They will have their own preferences and experiences with all the different modalities.”
He said that a trial treatment is often appropriate when a horse has a sore back, especially when diagnostic imaging doesn’t provide an exact answer.
Finally, Elliott reminded practitioners that “it’s one spine, nose to tail.”
About Dr. Christopher Elliott
Christopher Elliott, BVSC, MRCVS, MANZCVS, DACVSMR, was born and raised in Brisbane, Australia, and graduated from the University of Queensland’s School of Veterinary Science in 2007 with First-Class Honors. Since then, he has become board-certified in Sports Medicine and Rehabilitation. Elliott has experience working at FEI equestrian events in more than 20 countries. He has also been a Private Athlete Veterinarian, Team Veterinarian, Permitted Treating Veterinarian and Official Veterinarian. Elliott was the Veterinary Services Manager for FEI Competition at Wellington International for the 2023 Winter Equestrian Festival.