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Proceedings of the 16th

Italian Association of Equine Veterinarians
Congress

Carrara, Italy
January 29-31, 2010

Next SIVE Meeting:

Feb. 4-6, 2011 – Montesilvano, Pescara, Italy

Reprinted in the IVIS website with the permission of the

Italian Association of Equine Veterinarians – SIVE

http://www.ivis.org
Published in IVIS with the permission of SIVE
Diagnosis and treatment of back pain in horses
Tracy Turner
DVM, MS, Dipl. ACVS
Anoka Equine Veterinary Services - Elk River, Minnesota
The equine back is said to include the axial
skeleton from the withers to the sacroiliac
joint. Equine back problems are considered a
major cause of alterations of gait and per-
formance. Unfortunately the characterization,
localization, and identification of the painful
area can be problematic. The incidence of
back problems in general practice has been re-
ported as 0.9%.1 The clinical signs are said to
be highly variable. The purpose of this study
was to characterize the occurrence in a lame-
ness practice, to characterize clinical signs, to
describe treatments and outcome of the cases.
The diagnosis of back problems was made af-
ter a routine lameness examination, palpation
and manipulation. Thermography is routinely
used to evaluate the horses. Thermography in-
dicated the region of the problem in 98.5% of
cases. The diagnosis in each case is confirmed
using other imaging modalities including radi-
ography, ultrasonography, and scintigraphy.
Radiography was most useful in identifying
overriding dorsal vertebral spinous processes
and fractures of the withers. Ultrasonography
was most useful in identifying sacroiliac in-
juries, dorsal spinous ligament injuries, and
14 horses with muscle injuries. Scintigraphy
helped confirm 1 sacroiliac problem and 1
lumbar spinous process injury.
A variety of treatments are recommended and
utilized in horses. The treatments included
systemic anti-inflammatories, local anti-in-
flammatory injection, acupuncture, chiroprac-
tic, massage therapy, electro stimulation, mag-
netic therapy, therapeutic ultrasound, extra-
corporeal shockwave and training (exercise)
management. The only consistent therapies
were systemic anti-inflammatories and exer-
cise management.
157
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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Follow-up of horses with back pain indicate
90% return to work. However, about 15% of
those horses do not return to their previous
level and are used for other activities. Of the
85% of horses that return to their previous lev-
el of work, 60% do not need further therapy,
however the remaining 40% need to continue
to receive some therapy. The need for therapy
is based on the owner’s and trainer’s impres-
sion of the horse’s behavior.
The occurrence of back problems in our lame-
ness caseload is about 2.2%, which makes it
an uncommon problem. The distribution of
cases is interesting in that Thoroughbreds and
Paso Finos are over represented with regards to
our hospital population and Saddlebreds are un-
der represented. The other over representation is
with stallions and 10% of the horses with back
problems were stallions. Further analysis will
be necessary to determine if these anomalies are
conformational, occupational, or temperamen-
tal in origin.
The most common back problems we encoun-
tered are injuries of the sacroiliac joint.2 The
most common clinical signs associated with
sacroiliac pain was a shortness of gait behind,
lack of lateral flexion at the lumbosacral junc-
tion, particularly to the affected side and the
thermographic finding of a relative cold spot
at the level of the tuber sacrale. The diagnosis
was confirmed by ultrasonography with the
most common finding of changes in one or
both of the dorsal sacroiliac ligaments.
Injury of the vertebral spinous processes and
their associated ligaments directly or second-
ary to over riding spinous processes (kissing
spines) was the next most common problem.3
The most common problem associated with
these was a change in attitude of the horse, the
Published in IVIS with the permission of SIVE
horse would begin to “buck” or become “girthy”
or in the case of jumping horses the horse
would begin to refuse fences. Clinically these
horses would usually not show lameness but
palpation of the back would reveal an area of
“exquisite” pain, seen as marked ventro flex-
ion of the back when the painful spot is en-
countered. The other variation is the horse
would become rigid when palpated and if
forced to dorsiflex or flex laterally would be-
come highly agitated. Thermography was use-
ful in confirming the sight of inflammation.
Confirmation of these conditions required ra-
diology or ultrasonography and frequently a
combination of both. Radiography provides
excellent anatomical information with regards
to proximity of the dorsal spinous processes.
Studies have shown that the location of the
kissing spines ranged between the 11th tho-
racic vertebrae and the 2nd lumbar vertebrae.
The mean number of kissing spines per horse
was 4.3 with a median of 4. Forty-one percent
of horses have 5 or more spinous processes
involved, while 59% of horses have 2 to 4 in-
volved. Ninety percent of horses have in-
volvement of the anticlinal thoracic vertebrae
(T15) in the kissing spines while 10% of horses
have the kissing spines located caudal to T15.
The most common location is T15-16 fol-
lowed by T14-15 and T16-17. The further dis-
tance cranially or caudally from T15 the low-
er the frequency.
Fifty-one horses were evaluated as control
cases for comparison. These horses consisted
of 35 Warmbloods, 9 Quarter Horse types, 6
Thoroughbreds and 1 Morgan. Twenty of
these horses had kissing spines (39%): 12
Warmbloods, 4 Quarter Horses and 4 Thor-
oughbreds. Eighteen of the horses had 2 to 4
vertebrae involved while only two had 5 or
more processes involved. All involved the an-
ticlinal vertebrae (T15). Chi-square analysis
shows that the horses affected with kissing
spines and back pain have a higher prevalence
of 5 or more vertebrae involved (p<0.05). Ul-
trasonography showed damage to the liga-
ments, was more accurate in assessing the
boney edges of the spinous processes, and al-
lowed the operator to visualize scarring be-
tween two spinous processes.
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Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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A small percentage of horses are diagnosed
with muscle strains of the back.4 Clinically,
they presented much like the horses with dor-
sal spinous process injuries. The main differ-
ence in the exam was that thermography indi-
cated an abnormal pattern over the muscle
rather than over the midline. Ultrasonography
was the most important tool for confirming
these lesions. Thermography indicated the
area to examine and ultrasonography would
identify changes in the muscle tissue. There
were an equal number of increased echogenic-
ity lesions and areas of fluid accumulation
(multiple focal hypoechoic areas). Six of these
cases could not be confirmed ultrasonograph-
ically but were presumed to be muscle pain
based on the thermographic findings in con-
junction with the other clinical findings.
Withers injuries that range from fractures of
the processes to local osteolysis are the least
common causes of back pain. Radiography
was the most important diagnostic tool. One
other case was diagnosed as polysaccharide
storage myopathy diagnosed on muscle biop-
sy and one horse had a very ill-fitting saddle
with marked bridging.
The clinical signs of back pain are highly vari-
able and could not be solely used to differen-
tiate causes of back pain. Hence, the clinical
diagnosis of kissing spines has often been
considered challenging. Thermography is an
ideal tool to help differentiate when clinical
signs and behavior changes are associated
with the back. Thermography can detect sub-
tle (0.1o C) temperature changes, and in back
sore horses, depicts an array of inflammatory
patterns. The results of this study indicate a
90% positive predictive value for thermogra-
phy in the diagnosis of kissing spines in back
sore horses, i.e. if one of the three thermal pat-
terns described is present during an evaluation
of a horse’s back there is a 90% chance that
the horse has kissing spines. The patterns have
been described as “root signatures” and are
thought to reflect inflammation of nerve roots
from the spine. Whether this is true cannot be
determined by this clinical study, but the pat-
terns certainly were strongly associated with
spinous impingement. This clinical experi-
ence with thermography indicates its value for
Published in IVIS with the permission of SIVE
the evaluation of back pain and this study
shows that it enhances the clinical index of
suspicion more accurately than response to
palpation.
Treatment is usually multi factorial and no
one treatment can be expected to cure these
problems. Treatment needs to be based on
careful examination of intangibles these
would include the horse’s teeth, bitting, and
saddle fit. Secondly, exercise therapy is a
must. Exercise is designed to achieve 2 goals,
one is to stretch the top line and the other is to
improve the strength and flexibility. Another
hallmark of treatment is pain control, the
horse needs to have medication or injections
to ease the discomfort. Acupuncture and chi-
ropractic manipulations can be helpful. In ad-
dition, other therapies such as massage, thera-
peutic ultrasound, electrical stimulation, mag-
netic therapy appear to have the best effect
when used to relax the horse before exercise.
We found teaching the owner to perform some
of these as a routine before riding had psycho-
logical benefits if not physical ones.
The most common treatment protocol the au-
thor has used is a combination of shockwave
therapy, mesotherapy and exercise (SME).
This therapeutic regimen has proved to be
more effective in our cases than any other
treatments we performed. In the author’s ex-
perience, the most important aspect of any
treatment regimen was the exercise program.
Exercise must achieve the goal of the horse
moving freely forward in a relaxed frame
(“long and low”). If this goal was not achieved
or attempted, therapy simply failed. Shock-
wave and mesotherapy are modalities that
help achieve this goal. Shockwave effectively
eliminated the pain and would make the horse
willing to work. However, shockwave only
improved the willingness; as full stretching
was inconsistently achieved. As a result,
mesotherapy was added. Mesotherapy is a
technique of intradermal injection that is hy-
pothesized to work through type I and II nerve
fibers that can block pain transmission within
the spinal cord.3 Post-treatment, increased
willingness to stretch over its top line and
stepping further underneath and forward with
the rear legs were observed. Daily exercise
159
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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was key and ground poles and cavelletti exer-
cises were added to the program once the horse
was willing to stretch. We asked that the
horse’s frame only be changed by the rider
gently lifting the horse’s head and then com-
pressing the horse by asking the horse to move
into the bridle. It was imperative that the rider
not force collection at any time. When suc-
cessful, the treated horses showed initial im-
provement within 2 days, then progressive fur-
ther improvement during the exercise regimen
and with each subsequent treatment. This ther-
apy was effective on 86% of treated horses.
The author’s preferred treatment for sacroiliac
injuries is two-fold. The first phase is to inject
the sacroiliac joint region with 160 mg
methylprednisolone acetate and 8 mg triamci-
nolone. The purpose of the injection is strictly
for its anti-inflammatory and pain relieving
effect. This treatment is followed by con-
trolled exercise. Exercise consists of a thor-
ough warm-up that depending on the
owner/rider including physical massage of the
lumbosacral area or the application of thera-
peutic ultrasound before riding. The exercise
begins with the horse in a long and low frame
at the walk. Exercise is kept at the walk and
lateral exercises for the horse to step under
and cross over its hind legs are used. Walking
over ground poles and cavelleittis is also used
for the purpose of stretching the top line and
flexing the abdominal musculature. When the
horse begins stepping under (“over-tracking”)
the intensity of the exercise is increased. In
most horses this means trotting; however, the
trot induces pain in some horses and these rid-
ers are encouraged to exercise at the canter
then back to the trot. We have found this com-
bination of steroid and exercise to give us the
most consistent improvement.
Several factors play a role in the effectiveness
of treatment, including client compliance.
Horses under 5 years of age have a signifi-
cantly poorer response to treatment. Treat-
ment is 20% less likely to be successful in
horses with 5 or more vertebrae involved. Sad-
dle fit changes in horses helped 71% of the
time. This finding reiterates the need to assess
all aspects of the rider horse interaction when
dealing with back pain.
Published in IVIS with the permission of SIVE
REFERENCES
1. British Equine Vet Assn: Survey of equine disease
1962-1963. Vet Rec 77:528-538, 1965.
2. Tomlinson JT, Sage AM, Turner TA, Feeney D: De-
tailed ultrasonographic mapping of the normal
equine pelvis. Am J Vet Res, 62: 1768-1775, 2001.
3. Denoix J-M, Dyson SJ: Thoracolumbar spine. in
Ross MW and Dyson SJ (eds): Lameness in the
horse, WB Saunders, Philadelphia, 509-521, 2003.
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Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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4. Turner TA: Hindlimb muscle strain as a cause of
lameness in horses. In refereed section of Proceed-
ings of 35th Annual Meeting of Am Assoc of Equine
Practnr, 1989: 281-290.
5. Turner TA: Back soreness in horses. In Proceedings
of 49th Annual Meeting of Am Assoc of Equine
Practnr, 2003: 71-74.
6. Turner TA: Thermography, in Henson F(ed):
Equine Back Pathology: Diagnosis and Treatment,
Wiley-Blackwell, Cambridge, 2009, 125-132.