PHYSIOTHERAPY IN THE HORSE

In this article, Louise Carson looks at physiotherapy assessment of the horse, what we look at and why and what this may mean for you the farrier. In this case, the term ‘physiotherapy’ refers to what is practised by Chartered Veterinary Physiotherapists. Other professionals may well have a different way of assessing. On that note let me explain in a nutshell what Chartered Physiotherapists are as the title ‘physiotherapist’ is not protected in the veterinary field. All Chartered Veterinary Physiotherapists train first as human physiotherapists, currently this requires a three- or four-year full-time honours degree, to enable us to gain Chartered status. We then complete a further two-year university Masters level course in veterinary physiotherapy. This then allows us to join the Association of Chartered Physiotherapists in Animal Therapy (ACPAT) as category A members. Due to the level of university training and strong scientific background that this gives us, ACPAT physiotherapists are the only paraprofessional to be asked to join the veterinary team at the London Olympics next year.
Our human training and usually first jobs are within the NHS which means, love it or hate it, that we’re very used to working as part of a multidisciplinary team to achieve the best outcome for our patients. With our equine clients we generally expect to work with everyone that has an input including vets, farriers, saddlers, trainers and other professionals as well as the owner as everything each of us do has a direct impact, however subtle, on each of the others. Working alone we may well wonder why what we’re doing doesn’t seem to be having the expected effect, whereas working together we might have chosen a different option altogether.
SUBJECTIVE ASSESSMENT
(what the owner/other professionals tell us)
The assessment process begins with the first phone call from the owner, here, we gather a full history as to why they want physiotherapy for their horse, what has prompted the phone call, has there been an injury, a change in behaviour or performance or are they just wanting a maintenance check up? ACPAT physiotherapists work within the remit of the Veterinary Surgeons Act, so only work with the registered vet’s permission, so the next phone call is to them to make sure that they’re happy for the horse to be assessed and treated and to determine if the horse has any relevant veterinary history.
One of my first questions once I’m with the owner and horse is, 'does the farrier have any problems with your horse?' For example, does it struggle to have a limb taken off the floor, to hold it up, attempt to snatch it away and put it down, resent the limb being stretched forwards, or backwards, or put up on the tripod? Has this always been the case? When did it start, has it got better or worse? Is there anything that the farrier has tried that it seemed to prefer or dislike? Has the farrier commented on whether the horse has changed how it is wearing its shoes, have they done or wanted to do something to change it?
Whether you realise it or not, as the horse's farrier you hold a wealth of information as to how the horse is managing to maintain, or not, it’s skeletal system. By going through the shoeing process you are really challenging the horse’s balance mechanisms and that highlights any areas of weakness, tightness or flexibility by what the horse is or isn’t able to do for you. This is all the more obvious when it’s ability to cope with what you do, changes. The same goes for abnormal wear of the shoe or hoof wall. You may be happy that the foot is well balanced when you have finished, but the horse is still not wearing the shoe evenly when you next see it. Uneven wear may be due to muscle tightness or weakness, or a combination of both, or pain in a joint making the horse want to weight bear more on one side of the limb than the other. What you are finding may well tie in with what the trainer/rider are saying about the horse’s ridden work and subsequently what we find in our physiotherapy assessment.
There are many ‘cheats’ that a horse will adopt to avoid using a stiff, tight or painful area and are often thought of as training issues. Depending on how the horse is managed and it’s previous experiences coupled with the sensitivity and ability of the rider will dictate how strongly or subtly it lets you know that it’s not comfortable!
Common problems:
Example 1
Farrier notes: The horse is showing signs of concussive stress in its forefeet
Rider is finding: Horse finds it difficult to stay straight on a circle and wants to let its shoulders or quarters drift in or out. It struggles more as the circles get smaller. It is unable to hold rhythm with change of direction. It has poor downward transitions. It struggles with medium paces and is reluctant to rein back. The horse may be said to be ‘cold backed’ or resentful of saddling.
The why! A stiff thoracic spine – the area the riders sits on! Most of the lateral flexion in a horse’s spine comes from this area. If it is not able to achieve the amount of bend that it was designed for it will become stiff (if you don’t use it, you lose it) and often sore. The horse needs to be able to bend through this area to allow the forelimbs to come off the floor more easily. The horse is likely to be weak in its abdominal pectoral muscles as a result – or if it is weak in these muscles this may be why the spine has got stiff.
Hopefully this is picked up on before the horse has lasting stress damage to it’s forelimbs.
Example 2
Farrier notes: The horse finds it difficult to balance/shows reluctance to stand while one front leg is off the ground. This may be worse when you are using the tripod. Forelimb foot balance is poor or difficult to maintain.
Rider is finding: The horse falls in/out of it’s shoulder especially on a circle. It wants to let its head and neck bend to the outside or swing its quarters out.
Saddler notices: Asymmetrical muscling around the shoulder blades and wither.
The why! To compensate for a lack of lateral bend (for reasons as above) the horse fixes the muscles to stabilise either it’s inside or outside scapula (shoulder blade) during movement. By fixing this one scapula to make it more stable the horse puts more of it’s weight through this forelimb.
Note: ‘dishing’ may also be seen in the forelegs when the horse trots towards you in a straight line.
Example 3
Farrier notes: The horse finds it difficult to stand on one hind leg while the other is picked up.
Rider is finding: The horse doesn’t step under enough behind, doesn’t track up even though it is quite ‘active’ behind. Medium paces are difficult to achieve.
The why! There may be pain in the hind limb joints. If the horse is stiff in either the thoracic spine or lumbosacral junction the horse finds it difficult to bring its hind legs underneath. The horse may be lame in one or both of its hind legs, there is likely to be pain and stiffness in the lumbar spine and it should be noted that the sacroiliac joints are subject to greater shearing forces than normal.
Example 4
Farrier notes: The horse finds it difficult to stand on one hind leg while the other is picked up, as above, but also notes that it is difficult to lift one hind leg higher than the other.
Rider is finding: The horse is disuniting/bunny hopping in canter and struggling with transitions. It is also struggling to come downhill, either choosing to come down sideways or takes short, choppy steps.
The why! While this may also be due to hindlimb lameness as above, these signs are also strongly suggestive of spinal pain. There is stiffness and pain in the joint between the lumbar spine and the sacrum. This may be due to poor movement patterns as suggested with the other problems above, but can also be due to a direct injury to this area. There may be a history of the horse falling, slipping and leaving a leg out behind or a bad landing when jumping.
Physical assessment and examination
Initially I look at the horse standing, as this tells me many things before I even see the horse move. I will look from the front, the back, both sides and, if I can, from above.
First, is there any obvious muscle imbalance or lack of symmetry? For example, is one muscle group bigger compared to the opposite side? (Commonly seen in the shoulder and hindquarters) If there is mild to moderate muscle wastage at the hindquarters on one side, then the pelvic bones will appear more prominent. Such horses may find it harder to maintain the opposite hind leg off the floor for any length of time as it struggles to balance on its weaker and, therefore, less stable side. General conformation of the horse is also noted as although the bony structure of the horse can’t be changed, it is a significant contributor as to how the horse is able to move and what it needs to do to compensate for its shortcomings. However, there are many highly talented horses, often showjumpers and race horses, which appear to defy nature in what they are able to achieve given their conformation.
Secondly, is the horse wanting to rest a limb? If it’s always the same one then maybe there is a level of discomfort in that limb. The horse may dislike the joints in that limb being overly flexed or may need to move about a bit before it’s happy to have one of it’s other legs picked up while it gets itself balanced and comfortable. If the horse is often resting alternate limbs this suggests generalised muscle discomfort.
Thirdly, what type of ‘posture’ does the horse have? The most common, due to a variety of stresses, is where the horse has weak elongated abdominal muscles and it’s thoracic (rib cage area) and lumbar (behind the rib cage and before the pelvis) spine is in extension or ‘dipped’. The horse looks to have a grass belly.
Second most common ‘posture’ is generally caused by pain or weakness in the back. The abdominal muscles are constantly working and the spine is quite flat. The horse looks ‘herring gutted’.
The third frequently seen posture is often the result of hind limb pathology or weakness. The abdominal muscles are elongated towards the front of the belly and held tight towards the back. These horses look tucked up behind.
While the horse is standing I also look at the feet, noting any asymmetry in an individual hoof or mismatch. Although there will be variation depending on when the horse was last trimmed or shod; looking at the hoof-pastern angle, toe length, heel height, cracks in the hoof wall, shape, definition and frequency of growth lines as well as size, shape and position of the frog and bulbs of the heels will all give good indications of the ‘lines of stress’ within the skeletal system. This gives me a good idea where the horse is choosing to distribute most of it’s weight in each limb, which in turn indicates where the horse may be tight or weak or choosing to offload a painful limb.
Next I want to see the horse moving to see how it is managing to compensate for the points that I’ve noted. This allows me to assess if there is any lameness, and to identify areas of muscle tightness and weakness that will be affecting it’s performance. I watch the horse walk and trot in a straight line away from me, towards me and past me on as firm and flat a surface as there is available. As a physiotherapist, I’m looking to see how the horse’s feet land with each foot fall and the ‘flight path’ of each limb. Do they swing in or out? How does the left compare with the right? Does the horse take it’s leg as far forwards as it should be able to go and does it let it go backwards the full amount too? If not is it because that limb is painful so it prefers it on the ground for the least amount of time? Is it because the muscle structures that support that limb aren’t very strong so struggle to stabilise it while it is on the ground? Or is it because one of the other limbs is painful and the horse has needed to change its gait to accommodate it? I also look at how much the joints bend during movement, mostly at the fetlocks, knees and hocks, elbows and stifles. The shoulders and hips are covered by so much muscle, it is tricky to assess true movement at these joints whilst watching the horse move.
I also note how well it copes with the turn as it comes back towards me. Then I look at the horse turning very tight circles in both directions and backing up. Finally, I look at the horse on the lunge on it’s usual exercise surface, preferably a school. While assessing the horse’s gait on the lunge I am looking at the same things that I was when it was moving in a straight line, but also noting its ability to bend through the thorax, engage it’s hindquarters and lift off its forehand, how much movement there is in the horse’s back, especially at the lumbosacral junction (where the flexible parts of the horse’s spine have a joint with the sacrum, fused, part of the spine-it connects the horse’s hind quarters to the main body of the horse) and if the horse is able to have free movement of it’s tail, primarily where it leaves the body. I also assess how well the horse is able to cope with transitions/changes of pace both up the paces and back down.
I will occasionally examine the horse on a hard surface if I am concerned about joint related lameness. If the horse demonstrates abnormal behaviour under saddle or in harness, I may also ask to see it ridden or driven. This allows me to see how the horse reacts to the riding/driving style of it’s owner, enabling me to tailor the rehabilitation protocol. I will also look at the how the saddle fits the horse as this is often a culprit in limiting a horse’s ability to flex and move through it’s spine by restricting the muscle’s ability to move and work leading to stiffness, atrophy or pain.
Finally I get my hands on the horse! Depending on what I’ve picked up in the assessment, I will have a closer look at the horse’s range of movement in it’s joints, most commonly the head on neck, neck joints, flexibility through the thoracic spine and how well the lumbosacral junction is able to move. I also feel what the soft tissue tension is like between the scapula and rib cage. I then palpate all of the surface muscles paying close attention to the horse’s reaction to where I am palpating and how much pressure it can tolerate. I feel for areas that suggest muscle injury such as raised or depressed areas, heat (or sometimes an area that seems cooler than normal) and swelling. I also feel how elastic the tissues are and how much ‘give’ there is in a muscle. The tissue’s reaction to pressure will often give a good indication as to how long a muscle has been in it’s current state. Long term holding spasm tends to feel very hard and flat with little elasticity. A recent area of muscle spasm will be much more tender to the horse when it is palpated, but will feel firm and more elastic compared to a chronic injury.
If a horse is having physiotherapy treatment the muscle length and strength should be changing and along with it the horse’s movement patterns which may alter the stresses put through the hoof walls.
This is by no means definitive, as we will tailor what we look at more in depth or choose not to assess on that day entirely depending on the horse and handler in front of us at the time, the facilities that are available and even the weather as the safety of all concerned is paramount. The level of knowledge and experience that the Chartered Physiotherapist has will enable them to clinically reason their choices of assessment to accurately determine the nature of, if any, the horse’s problems. If any undiagnosed lameness is picked up, the owner is referred back to the vet.

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